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I 



The Journal 



OF 



Nervous and Mental Disease 

AN AMERICAN JOURNAL OF NEUROLOGY AND PSYCHIATRY 



FOUNDED IN 1874 
MANAGING EDITOR 

DR. SMITH ELY JELLEFFE 



WITH COLLABORATION OF 



DR C. W. ALLEN, Los Angeles, Calif. 
DR. C. E. ATWOOD, New York, N. Y. 
DR. PEARCE BAILEY, New York. N. Y. 
DR. LEWELLYS F. BARKER. Baltimore. Md. 
DR. B. BROUWER, Amsterdam, Holland 
DR. CARL D. CAMP, Ann Arbor, Mich. 
DR. C. MACFIE CAMPBELL, Boston. Mass. 
DR. LOUIS CASAMAJOR, New York, N. Y. 
DR. L. PIERCE CLARK. New York, N. Y. 
DR. HENRY A. COTTON. Trenton, N. J. 
DR. HARVEY CUSHING. Boston. Mass. 
DR. FREDERIC J. FARNELL, Providence, R.I. 
DR. BERNARD GLUECK. New York, N. Y. 
DR. MENAS S. GREGORY. New York, N. Y. 
DR. C. JUDSON HERRICK, Chicago, HI. 
DR. GORDON HOLMES, London, England 
DR. J. RAMSAY HUNT. New York, N. Y. 



DR. C. ARIENS KAPPERS. Amsterdam Holland 

DR. EDW. J. KEMPF, New York, N. Y. 

DR. GEO. H. KIRBY, New York, N. Y. 

DR. W. J. MALONEY, New York, N. Y. 

DR. ADOLF MEYER, Baltimore. Md. 

DR. L. J. J. MUSKENS, Amsterdam. Holland 

DR. GEO. H. PARKER. Cambridge, Mass. 

DR. E. A. SHARPE, Buffalo, N. Y. 

DR. THOS. W. SALMON, New York, N. Y. 

DR. GREGORY STRAGNELL, New York, N. Y. 

DR. OLIVER S. STRONG. New York, N. Y. 

DR. E. W. TAYLOR, Boston, Mass. 

DR. WALTER TIMME, New York, N. Y. 

DR. FRED. W. TILNEY, New York, N. Y. 

DR. WM. A. WHITE, Washington. D. C. 

DR. S. A. K. WILSON, London. England 



VOL. 55. JANUARY. JUNE, 1922 



NEW YORK 

64 West 56th Street 
1922 








KC 

3X1 
v. 55" 



3- 

ORIGINAL CONTRIBUTIONS 



PAGE 

The Present Status of Epicritic and Protopathic Sensibility and 
a Method for the Study of Protopathic Dissociation. By 
Joseph Bryne, M.D., M.R.C.S 1 

A Correlative Study of Endocrine Imbalance and Mental Dis- 
ease. By Nolan D. C. Lewis and Gertrude R. Davies 13 

Epidemic Encephalitis Simulating Myasthenia Gravis. By M. 

Grossman, M.D .33 

Occipital Lobe Embolism. By Andrew H. Woods, M.D 81 

The Loss of Three German Investigators, Alzheimer, Brod- 

mann, Nissl. By Professor Emil Kraepelin 91 

Clinico-Pathologic Notes on Solitary Tubercle of the Spinal 

Cord. By William Thalhimer and George B. Hassin 161 

Juvenile Paresis Associated with Hypopituitarism and Sym- 
pathicontonic Trend. By Theophile Raphael, M.D., and 
Sherman Gregg, M.D 194 

Progressive Cerebral Hemiplegia : Its Pathogenesis and Differ- 
ential Diagnosis. By Alfred Gordon, M.D 200 

Delirium Acutum and Primary Sinus Thrombosis. By Prof. Dr. 

K. Herman Bouman and Dr. B. Brouwer 273 

Pachymeningitis Cervicalis (Luetica) with Unusual Features. 

By Moses Keschner, M.D 294 

The Treatment of General Paresis by Inoculation of Malaria. 

By Professor Dr. Wagner-Jauregg 369 

Treatment of Paresis by Inoculation with Malaria. By Dr. 

Honorio F. Delgado 376 

Diagnostic Value of Vegetative Disturbances in Diseases of the 

Nervous System. By Dr. E. A. Spiegel 465 

Neurosyphilis in Ex-Service Men. By Dr. R. H. Price 485 

Blood Creatinin Findings in Five Cases of Corpus Striatum 

Disorders. By Dr. J. Raphael and F. C Potter 492 

Society Proceedings: 

Xew York Neurological Society, and The Section of 
Neurology of The Academy of Medicine. . .41, 103, 301, 497 

Boston Society of Psychiatry and Neurology 114, 310 

Association for Research in Nervous and Mental Diseases. 390 



iv ORIGINAL CONTRIBUTIONS 

PAGE 

Current Literature 52, 121, 210, 318, 520 

I. Vegetative or Visceral Neurology 121, 318 

1. Vegetative Nervous System 121, 318 

2. Endocrinopathies 121, 337 

II. Sensori-Motor Neurology 52, 210, 346 

1. Peripheral Nerves: Radicular Syndromes .... 346, 506 

2. Cranial Nerves 507 

3. Spinal Cord 516 

4. Midbrain and Cerebellum 52, 137 

5. Brain ; Meninges 59 

6. Brain 62, 210 

III. Symbolic Neurology 142, 237, 415, 536 

1. Psychology — Neuroses — Psychoneuroses 142, 236 

IV. Social and Forensic Neurology 444 

Book Reviews 70, 148, 240, 353, 458 

Obituaries 259, 271, 463 



VOL. 55. JANUARY, 1922. No. 1 

The Journal 

OF 

Nervous and Mental Disease 

An American Journal of Neurology and Psychiatry, Founded in 1874 



Original articles 



THE PRESENT STATUS OF EPICRITIC AND PROTO- 

PATHIC SENSIBILITY AND A METHOD FOR 

THE STUDY OF PROTOPATHIC 

DISSOCIATION 

By Joseph Byrne, M.D., M.R.C.S. 

FORDHAM IXIVKRS1TY, NEW YORK 

The division of sensibility in the peripheral nerves made by Head 
and Sherrin (1) into three forms, viz., epicritic, protopathic, and 
deep, has been attacked from many quarters. The onslaughts for 
the most part have centered on that form of dissociated sensibility 
in which the epicritic elements are suppressed, the protopathic ele- 
ments being retained with their well-known characteristics, viz. : sud- 
den entry into consciousness, poor localization, wide radiation, over- 
reaction, and inability to name the stimulus. 

In the regeneration period after nerve section and suture Rivers 
and Head (2) found that this type of dissociation occurred as the 
result of the unequal rate of regeneration in two separate sets of 
systems, the one mediating the protopathic elements recovering 
function somewhat in advance of the set which mediates the epi- 
critic elements. 

The attackers, 1 chief among whom are to be mentioned Trotter 
and Davies (3) in England, and Boring (4) in America, have not 

1 Since the World War many articles have appeared in the literature 
attacking the dissociation hypothesis. A glance at these contributions shows 
that however useful they may be from the clinical standpoint, they fall far 
short of supplying a basis for scientific criticism of any theory of sensation. 
The only work so far submitted, in Knglish and American literature, worthy 
of consideration in this respect is the work of Trotter and Davies and of 
Boring. 

1 



2 JOSEPH BYRNE 

succeeded in disproving the dissociation hypothesis. Indeed when 
subjected to critical analysis the clinical studies of Trotter and 
Davies lend strong support to Head's main argument whilst the 
studies of Boring, notwithstanding somewhat extravagant claims 
on the score of introspective analysis, are grossly defective in many 
essential respects, not the least of which is an apparent predisposi- 
tion to prove something against the dissociation hypothesis. 

The writer has. made numerous studies during the past decade 
upon regeneration in sensory nerves after all sorts of injury and has 
come to the conclusion that with some modifications Head's position, 
at least in regard to dissociation, is practically impregnable. The 
" protopathic stage " as Head calls it may not, it is true, always 
stand out without admixture of the epicritic elements. On this point 
Head's opponents, in the author's opinion, have achieved some suc- 
cess. The limits of the epicritic ranges for heat and cold are, more- 
over, not fixed and each of these forms seems to be an arbitrarily as- 
sumed entity since the specific element of heat (warmth) or cold, of 
all degrees, runs in a series that forms a continuum. Here again 
the attack of Head's opponents seems to have registered effectively. 
Spatial discrimination as tested by the compass points simultane- 
ously applied is regarded by Head as f the most delicate form of epi- 
critic sensibility and the last of the " epicritic forms " to recover 
after nerve suture. Head's opponents regard this test as in reality 
a test for a form of deep sensibility and the author's studies (5). in 
which he made compass tests on the deep fascia of the thigh, show 
that, at least in part, this form of sensibility is mediated by infra- 
cutaneous mechanisms. 

Head recognizes three forms of protopathic sensibility, pain 
(pricking), heat, and cold, each of which he regards as a simple 
entity. As a matter of fact, however, each of these, even when 
evoked by a punctiform stimulus, is a complex of hurtful (affective) 
and non-hurtful (critical) elements. Thus in certain dissociations 
the sharpness of pin-prick is shown to be an element separate and 
distinct from the hart element since it may be preserved intact al- 
though the hurt element has been suppressed. And similarly 
warmth, and the specific sensation of cold, may be retained where 
the element of hurt or unpleasantness has been abolished. These 
forms of dissociation found by the author (5) in a case of syringo- 
myelia show that the fundamental thing in protopathic sensibility is 
the unlocalized, immeasurable, uncontrolled hurt or affective ele- 
ment (unpleasantness, change of state, etc.) as opposed to the intro- 
spectively measurable, more or less zuell-de fined sensation of sharp- 



PRESENT STATUS OF SENSIBILITY j 

or pointedness (e.g., of pin-prick), and of warmth and cold, 
each of which must be classed with the critical elements. Head's 
apparent failure to appreciate the significance of the dissociable 
elements found, even in what appears to be the simplest form of 
punctiform stimulation, has led him into a difficult maze of specula- 
tion. Thus he insists that once the peripheral nerves enter the 
spinal cord, i.e., at the first synaptic junction, epicritic and proto- 
pathic forms of sensibility are no longer encountered and yet in cer- 
tain cases of syringomyelia the critical elements (pointedness and 
touch) of pin-prick may be retained unaffected, or but slightly im- 
paired, where the affective (hurt element) is completely abolished. 
The similarity, moreover, between the type of sensibility retained irr 
thalamic dissociation and that found in protopathic dissociation 
during the regeneration period after nerve section and suture is so- 
marked as to warrant the conclusion that they are identical in nature 
as well as in the mechanism of their production, viz., abolition or 
impairment of function relative or absolute in the critical mechanism. 
A- the author (5) has pointed out, the dissociations encountered 
in syringomyelia and in thalamic dissociation clearly show that the 
critical pathways, both superficial (epicritic) and deep, retain their 
anatomical and functional individuality all the way from the peri- 
phery up to the thalamus. Head's contention, therefore, anent the 
intricate regrouping and integrations of afferent impulses, as one of 
the principal functions of the spinal cord, seems not only superfluous, 
but in actual conflict with demonstrable facts. The sensation known: 
as "heat" evoked by temperatures over 45 C. is a complex of the 
specific element warmth plus the affective element of burning or 
stinging, and each of these elements is dissociable from the other in 
both cord and thalamic lesions. Head nevertheless insists upon his 
epicritic form of heat in spite of the fact that in syringomyelia tem- 
peratures of 55 to 70 ° C. may evoke only the sensation of warmth. 
Cold is also a complex of the specific critical element cold plus the 
affective, unpleasant or hurt element and again the author has ob- 
served cases (unpublished) in which these dements were dissoci- 
ated. The fact that cold is analgesic under certain conditions and 
algesic under other conditions seems to have baffled many observers, 
including Head and Boring. Head makes a strong point of the 
pleasurableness evoked by warmth as indicating a specific form of 
protopathic sensibility but it has long ago been shown that stimuli 
otherwise painless or even agreeable becomes painful when their in- 
tensity approaches a degree that threatens tissue injury. Change 
of state is the fundamental thing in all stimulation and the exaltation 



4 JOSEPH BYRNE 

consequent upon activation of any function, within limits not antago- 
nistic to well being, local and general, sufficiently explains the agree- 
able features of warmth. In thalamic dissociation the over-reaction 
to warmth is not an indication of an exalted specific form of proto- 
pathic sensibility. It merely represents the response to an innocuous 
stimulus where the affective mechanisms have been released from 
critical control which, as the author has pointed out (5), is exerted 
directly and mainly at the thalamic level, and not circuitously through 
the cerebral cortex as Head and Holmes (6) insist. It should be 
kept in mind that the thalamus mediates only the grosser affective 
elements and that even these may be in part mediated also by the 
inner layers of the cerebral cortex. In the course of its develop- 
ment the thalamus should not be regarded as an isolated entity but 
as closely related structurally and functionally with more primitive 
elements in the cerebral cortex. Of the epicritic and protopathic 
forms of sensibility laid down in the original classification of Head 
and his colleagues only one form remains as a distinct entity, viz. : — 
light touch, and attempts have been made to remove even this from 
the category in which Head placed it by Trotter and Davies who re- 
gard touch as merely dynamic contact and introspectively distin- 
guishable from pressure or static contact. It seems, therefore, that 
after fifteen years of trial Head's classification has little to recom- 
mend it. In the author's opinion it has retarded rather than aided 
progress in the clinical study of sensation on account of the confu- 
sion it has caused in the minds of students and teachers alike not 
only because of its fundamental defects as a classification but also, 
in great measure, because of its formidable ill-fitting terminology. 

In Head's classification no mention is made of deep protopathic 
sensibility although this latter is a commonplace of clinical study 
and is the form par excellence found in the viscera. Compare in- 
testinal colic, testicular pain, etc. This is further reason why Head's 
classification should be dropped although the tests employed by him 
might with benefit be retained as in the author's classification (5) 
and perhaps be made the standard for sensory examinations in hos- 
pitals and private practice throughout this country. Head's fail- 
ure to distinguish between the fundamental affective element in his 
protopathic sensibility and the critical or specific elements led him 
to speak of protopathic heat and cold as distinct forms of sensibility 
with the result that psychologists and clinicians, unable to verify his 
findings, or to harmonize them with well-established facts, have been 
led to deny altogether the existence of protopathic sensibility as a 
distinct form. Had Head not insisted too stringently upon the oc- 



PRESENT STATUS OV SENSIBILITY 5 

currence of a " stage " of protopathic sensibility and had he appre- 
ciated the fact that the common fundamental purely affective ele- 
ment underlies all his protopathic forms, giving in each instance 
enhanced vividness to the superposed critical elements, his work 
would have been almost beyond criticism. As it stands, its great 
merit consists in the demonstration after a cutaneous nerve injury 
of protopathic dissociation, i.e., abolition or impairment of sensi- 
bility for the critical elements, the affective elements being retained 
and exhibiting protopathic characteristics. 

A glaring defect in our clinical methods of studying sensation 
and one often complained of by psychologists is the absence of any 
attempt at introspective analysis. But even the psychologists them- 
selves seem to have grown timid on this subject and have failed for 
once to come to the aid of the clinician. The author has found in- 
trospective evaluation such an important aid to clinical study, even 
when the introspections are of the most elementary kind, that he 
ventures to set forth in detail the simple method he has found use- 
ful in unraveling the vexed problems of dissociated sensibility. 

Method of Studying Protopathic Dissociation 

In the regeneration period after injury or division of a peri- 
pheral nerve the protopathic type of dissociation is the one most 
usually encountered, whereas in spinal cord lesions, the dissociation 
best known to clinicians is of the critical type, i.e., in which the af- 
fective elements are abolished or impaired, the critical elements be- 
ing retained. Compare the dissociation found in syringomyelia and 
related conditions. This reversal of type in the dissociation found 
commonly in spinal cord lesions as contrasted with that so commonly 
found in peripheral nerve injuries points clearly to two separate 
systems of pathways, one for impulses representing the affective 
elements, and another for impulses representing the critical elements. 
But the evidence for the existence in the peripheral nerves of these 
two systems does not rest merely on the occurrence of protopathic 
dissociation, since direct evidence of critical dissociation like that 
found in syringomyelia is found in certain cases after nerve injury. 

Compare the Horsley case in which, after removal of a small 
tumor from the nerves at the base of the brain by Horsley, Head 
(7, p. 108) found sensibility absent for pricking and for 55 C. but 
preserved for light touch and 43 C. Compare also the " Triangle " 
in the Human Experiment (2) in which Rivers and Head found 
sensibility for pricking and for the affective or hurt elements of 



6 JOSEPH BYRNE 

heat (above 50 C.) absent, that for light touch and for the critical 
element (warmth) of 43 ° to 49 ° C. being preserved. Compare 
finally the case reported to the New York Neurological Society by 
Dawbarn and Byrne (8) in which after division and suture of the 
radial nerve in the upper arm sensibility for light touch and for the 
compass points simultaneously applied returned in a considerable 
area on. the dorsum of the hand far in advance of that for pricking 
and for temperatures of all ranges. 

In these cases it will be noted that sensibility was found present 
or absent for certain groups of critical elements (superficial critical 
stimuli) whereas, for the gross affective elements of pricking, of 
heat above 55° C., and of cold of all grades (superficial affective 
stimuli), it was found absent not fractionally as in the case of the 
superficial critical elements but as a zvholc. 

The last link in this chain of evidence was supplied when the 
author (5) was enabled to show that in lesions such as tumors caus- 
ing compression of the spinal cord, dissociation of the protopathic 
type was by no means of infrequent occurrence. In the spinal cord 
and peripheral nerves, therefore, it must be admitted that there are 
at least two separate and distinct anatomical systems of pathways 
for the conduction of afferent impulses. One of these systems 
mediates, the more or less unlocalized, unmeasured, uncontrolled 
affective or quality elements (hurt, pleasure, change of state) and 
the other the introspectively measurable, well-localized, controlling 
critical or quantitative elements (sharpness, size, shape, warmth, 
specific sensation of cold and spatial discrimination, posture, pas- 
sive movement, etc.). 

The affective system has its main terminus in the optic thalamus 
whereas the main destination of the critical system is the cerebral 
cortex. Compare Head and Holmes (6). Each of these systems 
conducts afferent impulses not only from the skin and superficial 
parts but also from structures that are deeply situated, such as 
muscles, tendons, etc. ; and as each system of necessity has receptor 
mechanisms not only at or near the surface of the body but also in 
the deeper parts it seemed desirable to the author (5) for clinical, if 
for no other reasons, to further divide each of the great systems 
with reference to the location of its receptor mechanisms. This 
makes four separate sets of afferent pathways in the peripheral 
nerves, viz. (1) superficial critical, (2) superficial affective, (3) 
deep critical, and (4) deep affective, each set representing some 
more or less distinct phase of development of the sensory system. 
Each of these four sets of pathways remains separate and distinct 



PRESENT STATUS OF SENSIBILITY 7 

from the others, each retaining in the spinal cord, brain-stem and 
optic thalamus, its functional and anatomical individuality if not a 
spatial allocation that is grossly or microscopically demonstrable. 

This simple classification has been found by the author to be 
of great practical aid in sensory studies. It seems especially well 
adapted for the brief summarization of sensory findings so essen- 
tial for diagnostic purposes. It also supplies a satisfactory means 
of correlation between physiological and psychological data, em- 
phasizing as it does the radical distinction between the critical or 
intellectual elements on the one hand and the affective or feeling 
elements on the other. 

Under normal conditions each critical system or set of pathways 
functions in conjunction with the corresponding affective system, 
the former controlling the latter in the interests of the more com- 
plex, cognitive or reasoned methods of adjustment whereby, through 
experience, memory, judgment, etc., aided by the projicient receptor 
mechanisms (e.g., of vision, hearing, etc.), injurious objects may be 
avoided by locomotion without risking possible injury from direct 
contact, as opposed to the more primitive, unreasoning, instinctive 
methods of reflex withdrawal by shortening (flexion-reflex) after 
direct noxious contact. 

Many observers have failed to convince themselves that proto- 
pathic dissociation occurs regularly after nerve injuries because they 
attempted to institute comparisons between threshold values ob- 
tained in each of the two great general systems, affective and critical, 
without realizing that in practice every stimulus, whether it be puncti- 
form or areal, makes appeal in greater or less degree to both of these 
systems. This holds especially for stimulation tests made in the ran- 
dom method which Boring (4) in particular used. Thus in cuta- 
neous hyperalgesia the lightest von Frey hair may evoke a sensation 
preponderately affective, viz., hurt as opposed to contact, whereas, 
under normal conditions pricking at a low pressure, e.g., 1.0 or 2.0 
grammes, and in certain cases of syringomyelia even at a pressure of 
37.0 grammes or more, may evoke a sensation that is preponderately 
critical, viz., sharpness (pointedness) as opposed to hurt. Intro- 
spective analyses based on methods of stimulation which do not 
take into consideration differences in threshold values dependant on 
the situation in relation to the body surface as well as upon the nature 
(i.e., whether belonging to the affective or critical system) of the re- 
ceptor mechanisms stimulated can have little value in determining 
the presence or absence of dissociation of sensibility. The absence 
or impairment of sensibility as a whole for the critical as well as for 



8 JOSEPH BYRNE 

the affective elements must be established more or less accurately by 
the determination of threshold values but a reliable basis for the im- 
mediate comparison of threshold values obtained by stimuli that are 
preponderately critical with those obtained by stimuli that are pre- 
ponderate^ affective is wanting. In the author's opinion the classi- 
fication of the sensory pathways on the twofold basis, viz., (i) ac- 
cording to the nature of the elements which each system mediates, 
i.e., affective or critical and (2) according to the nature and location 
of the receptor mechanisms, i.e., whether superficially or deeply 
situated, is a distinct help in the study of dissociation since it serves 
to keep before the mind of the examiner the mechanisms to which 
each stimulus makes particular appeal. But no method is complete 
which does not make provision for introspective analysis in one 
form or another. The procedure which the author has found most 
serviceable in testing cutaneous sensibility consists first in marking 
off a definite area within the affected skin area and then applying 
affective stimuli in a random manner and recording the introspective 
evaluations for the critical and affective elements represented in each 
stimulus. The evaluations are so recorded that comparison of the 
state of sensibility presented by the affected area with that presented 
by a corresponding area of normal skin is possible on a quantified 
basis. This can be readily done by using + marks in the manner 
set forth below. When water at 50 C, in a silver test tube with a 
definite area of contact, is applied momentarily and lightly to the 
normal skin, e.g., on the dorsum of the hand, appeal is made to sev- 
eral types of receptors. The first sensation experienced is that of 
contact which is felt at once. Next in order warmth is felt and be- 
neath this appears the hurt or affective element which is over- 
shadowed by, and under control of, the two other (critical) ele- 
ments. In conditions exhibiting defective critical sensibility the 
hurt element overshadows the critical elements (touch and warmth) 
with resulting overreaction. These two conditions of sensibility can 
be contrasted by setting down the introspective evaluations for the 
different elements of the stimulus 50 C. as follows : 

Elements JJormal area Affected area 

Touch ..'. + + + + 

Warmth ++ + 

Hurt + + + + 

The evaluations for cold at 20 C. may be similarly contrasted 
as follows : 



PRESENT STATUS OF SENSIBILITY 9 

Elements Normal area Affected area 

Touch -j- -j- 4- 

Cold (specific element) + + + + + 

Unpleasant feeling -j- + + + 

For pricking at 3.0 grammes, or more, pressure the evaluations 
might stand : 

Elements Normal area Affected area 

Touch -f+ 4. 

Pointedness (sharpness) + + + -f- 

Hurt + + + + 

In doubtful cases tables such as these emphasize at once the 
presence or absence of the subjective overreaction (hurt element, 
etc.) so characteristic of protopathic dissociation. In addition to the 
subjective overreaction set down in the tables, the presence or ab- 
sence of other protopathic characteristics may be recorded such as 
objective overreaction (withdrawal), radiation locally of the stimu- 
lus effects, reference, persistence, poor localization and impaired 
ability to name the stimulus. Such a table showing the typical 
characteristics of protopathic dissociation, e.g., for heat at 55° to 6o° 
C, might run : 

Elements Normal area Affected area 

Touch + O 

Heat (warmth) + + + O 

Subjective over-reaction (hurt, 

etc.) 4- + + + 

Objective over-reaction (with- 
drawal) 4- . + + + 

Localization + + + 4- or O 

Radiation + + + + 

Reference O + or O 

Persistence O -+- 

Ability to name stimulus + + + O 

It is well known that practice with any tests reduces the thresh- 
old value markedly in some instances even as much as fifty per cent. 
It is therefore advisable that in every case before testing, the patient 
should have some training in the threshold as well as in introspec- 
tive studies so that in the final tests the answers may be promptly 
and spontaneously given. In the introspective tests each element 
should be reported in the order of its appearance and according to 
the degree of its intensity. 

The applications of each stimulus may be few or many depending 
upon circumstances, the elements being evalued and charted accord- 
ing to the scheme just outlined. At the end of the examination the 



io JOSEPH BYRNE 

average of the evaluations is determined for each element by divid- 
ing the total numbers of -f-'s charted for each element by the num- 
ber of applications of the stimulus. In the final chart the averages 
for each element are set down against each other for comparison. 
By the aid of this simple method, elaborated and adapted to circum- 
stances, the author has found no difficulty in demonstrating to his 
satisfaction protopathic dissociation not only after severe lesions of 
the peripheral nerves but also in spinal cord lesions and in the or- 
dinary conditions in which pain is associated with minor grades of 
nerve injury of mechanical or chemical origin, e.g., contusions, in- 
fections, etc. 

Many investigators have fallen into error by assuming that in 
order to obtain dissociation of sensibility one of the two chief sets 
of elements, i.e., critical or affective, must be completely suppressed 
as a whole whilst the other remains practically unimpaired. After 
section of a cutaneous nerve if stimuli, such as very heavy von Frey 
tactile hairs, be used, sensibility may be found but slightly impaired 
since such stimuli make appeal to the deeply situated receptor 
mechanisms of afferent paths that may not have been involved in 
the nerve section. Just such an error was made by Trotter and 
Davies (3) who relied on introspection to distinguish between 
dynamic contact (light touch) and static or pressure-contact (pres- 
sure-touch). No wonder these observers found that sensibility for 
critical and affective elements became restored simultaneously in the 
affected area after nerve section and suture. 

The author believes that the time is ripe for clinicians to come to 
a more thorough understanding of the significance of the sensory 
tests. As at present made and recorded they are practically worth- 
less and represent just so much waste of time and effort. Witness 
the summaries containing such expressions as "hypesthesia (or hy- 
peresthesia below the level of the umbilicus." With our present 
knowledge of the multiple appeal of all kinds of stimuli, both 
punctiform and areal, and of the fundamental critical and affective 
components present in all forms of stimulation, it is amazing to find 
neurologists using such terms as hypaesthesia and hyperesthesia to 
signify sensory impairment or exaltation. As such terms grossly 
misrepresent the actual sensory changes, they should have no place 
in our clinical histories or reports not to mention text-books. The 
employment of a method such as laid down in this paper would 
obviate all such difficulties and would give sensory tests a diagnostic 
value which under present methods they cannot possibly have. As 



PRESENT STATUS OF SENSIBILITY n 

at present used by the majority of neurologists the sensory tests 
have little significance beyond the bare information that this or that 
form of sensibility is or is not lost or impaired. Interpretative 
evaluation is altogether missing. The method evolved by the author 
has, amongst other things, the great advantages that by it the sen- 
sory tests can be reduced to the extreme of simplicity so as to be 
available for the general practitioner in routine clinical examinations 
and for the neurologist's hurried preliminary or diagnostic exami- 
nations as opposed to the later, more painstaking examinations made 
possibly with a view to research. In the four divisions of the 
author's classification, viz., (i) superficial critical, (2) superficial 
affective, (3) deep critical, and (4) deep affective, only one type 
of stimulus need be selected as representative of each division. 
Thus taking light touch (cotton or the finger tip) as representative 
of superficial critical stimuli, pin-pricking of superficial affective, 
posture and passive movement of deep critical, and pressure-pain 
(pinching, etc.) of deep affective, we have a means of making a 
rapid sensory examination which, from the point of view of in- 
terpretative evaluation, far excels the majority of sensory' exami- 
nations as at present made even by otherwise skilled neurologists. 
This simple plan calls for just four sensory tests, viz., light touch, 
pin-pricking, posture and passive movement, and pressure-pain, all 
of which can be made in a few moments without the use of instru- 
ments other than an ordinary pin. Hitherto, thanks to the failure of 
teachers of neurology to appreciate their significance, the sensory 
tests have been made a sort of Oiinese puzzle for the general prac- 
titioner and as a conseqeunce have been generally so far overlooked 
in routine examinations, inside and outside of our hospitals, as to 
find no place in the clinical records. The method here offered to 
the profession should mark the beginning at least of a movement in 
the direction of clinical progress. 

Conclusions — (1) The division of sensibility into epicritic, pro- 
topathic and deep is incomplete and misleading. (2) The terms 
"epicritic" and " protopathic " in the sense in which Head, their 
originator, uses them, that is as including so many distinct forms 
of sensibility, are arbitrary and misleading and should be discarded. 
(3) The clinical study of sensory defects in addition to threshold 
tests should include some attempt at introspective analysis without 
which the various types of dissociated sensibility are likely to be 
overlooked. (4) Some simple standardized form or chart for the 



12 JOSEPH BYRNE 

clinical study of sensory defects should be adopted in the hospitals 
and medical schools throughout the country. 
244 West ioist St. 

BIBLIOGRAPHY 

1. Head, H., and Sherren, J., Brain, 1905, xxviii, 116. 

2. Rivers, W. H. R., and Head, R., Brain, 1908, xxxi, 323. 

3. Trotter W., and Davies, H., Jour. Physiol, 1909, xxxviii, 134. 

4. Boring, E. G., Quar. Jour. Exp. Physiol, 19 16, x, 1. 

5. Byrne, J., Alienist and Neurologist, July, 1918. 

6. Head, H., and Holmes, G., Brain, 1911-12, xxxiv, 102. 

7. Head, H., Rivers, W. H. R., and Sherren, J., Brain, 1905, 28, 99. 

8. Dawbarn, R. H. M., and Byrne, J., Jour. Nervous and Mental Dis., 1916, 

xiii, 150. 



A CORRELATIVE STUDY OF ENDOCRINE IMBALANCE 
AND MENTAL DISEASE 

By Nolan D. C. Lewis and Gertrude R. Davies 

(Continued from p. 512) 

Case 18. American, male, aged thirty-eight, single, seaman. 
Mental Diagnosis. Schizophrenia with paranoid develop- 
ment. 
Endocrinosis. Hyperthyroidism associated with pituitary 
disfunction. 

History. — He was brought up in a tough district of a great city. 
He always felt inferior as his frame was small and his bones deli- 
cate like a girl's. At school he did poorly and wanted to cry in 
shame when pupils surpassed him. 

He saw negro boys commit pederasty when he was twelve, and 
he had his first heterosexual experience at this age. He early 
learned to be on his guard against perverts. He first worked as a 
cash boy in a store but people teased him and he quit. He tried 
other jobs and night school but couldn't get on anywhere. 

At nineteen he had his only love affair but he felt inferior, as 
if he should step aside and let some superior fellow win the girl, 
so he withdrew, and wandered over the country from job to job. 
He wanted to see the world. 

At twenty-two he joined the Navy and reenlisted three times. 
Between each enlistment he roamed around a while in civil jobs. 
In the Navy he learned there were two classes of men, those who 
stood up for their rights and those who gave in. He noticed that 
perverts belonged to the soft, easy going type. He could always 
mimic girls and women and in fancy dress could pass for a girl, 
but it was dangerous to do so for some men might jump to the con- 
clusions that he was a pervert. He felt less strong and athletic 
than some fellows on shipboard, and was always on his guard lest 
others should suspect him of being a pervert. He trained himself 
to resent instantly any aggression. 

»3 



14 NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 

He kept a good deal to himself and felt lonely. He communed 
with himself and finally heard voices. They talked to each other, 
and he listened or sometimes he joined in the conversation. It was 
a comfort in his loneliness. The voices said he held communion 
with God. It had been noticed on shipboard for a long time that he 
had queer beliefs, but his behavior remained good and he did his 
work. He knelt like a fire worshiper and made obeisance to his 
cigarettes. One day he rushed into the captain's cabin and delivered 
a message he had received from God through his mother as to the 
course the ship should take. 

He was sent to St. Elizabeths. He had hallucinations, was 
talkative, very argumentative, emotionally unstable, and very sus- 
picious. He had no insight and considered himself an object of 
persecution, and tried to reason out why. 

He was too suspicious and resistive to enter our ward until May. 
We were then able to win his confidence partially. He was still 
pretty suspicious and looked about the office for a dictaphone. He 
believed in his delusions and felt bitter over his incarceration. He 
would harangue for hours about his grievances and felt we were not 
sympathetic enough over them. If he had been a pretty girl, he 
said, we would have paid more attention to his troubles. He was 
extremely conceited and thought he knew more than any of the 
physicians. 

Gradually he talked of his hallucinations. The voices at first 
had been insulting and knew all his sins. He could hide nothing 
from them, so he had confessed all to them and made peace with 
them, and then they became friendly and talked on pleasant subjects. 
When we tried to explain these spirits inside him as splits of his 
own mind, he said he could not believe it for they often told him 
interesting things that he was sure he had never known before. 
He admitted, though, that while at first they came from a distance 
he had gradually pulled them inside his head, and could now turn 
them off and on at pleasure. He could thus control them, and 
looked on them as seven spirits inhabiting one body. 

He did not consider it desirable to unite them into one mind as 
we advised for it was- so interesting and comforting to have them 
talk when he was lonely. He wouldn't want to lose them any more 
than a father would wish his children to die. He composed a poem 
called " Babies in Fairyland." 

Since he was reluctant to give up his schizophrenic conversation? 
we urged that he pay close attention to his behavior and make sure 
that it harmonized with the ideas of society, and that if his behavior 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 



■5 



was acceptable nobody would bother much about his beliefs. He 
grasped the point readily and admitted that his rushing with his 
divine message to the captain was a great mistake, and that he 
would be very careful in the future to do nothing that would meet 
with disapproval. 

In July after three months' treatment the ward nurses reported 
that his disposition had greatly improved, he was agreeable, cheer- 
ful, and worked well, argued no more, said nothing about his former 
supernatural beliefs, but laughed over some of them, and kept much 
to himself, and read books on science and art. It was noticed he 
disliked women. He felt able to earn his own living outside and 
was hopeful of soon regaining his freedom. 



Outlixe of Case 18 

Physical 

Slender type of skeleton. 
Skin smooth, dark brown 

over entire body. 
Hypertrichosis. 
Front teeth protruding 

outward from alveolar 

process. 
Hyperhydrosis. 
Positive Vigoroux sign. 
Tremor of fingers. 
Reflexes all hyperactive. 
Eyes protrude distinctly. 
Pupils dilated and active. 
Mild tachycardia. 
Thyroid gland slightly 

enlarged. 



Laboratory 

Wassermann negative. 
Blood pressure 13 %o. 
Blood uric acid 0.85 mg. 
Blood urea 22 mg. 
Blood creatinine 2.6 mg. 
Thyroid function test: 

Moderate hyperthy- 

roid reaction. 
Sugar tolerance test: 

Delayed absorption 

phenomena. 



Mental 

A believer in occultism 
and Divine healing. 

Visual and auditory hal- 
lucinations. 

Effeminate nature. 

Argumentative. 

Ideas of persecution. 

Systematized delusions. 

Resistive. 

Feelings of influence. 

Auditory hallucinations, 
at first unpleasant, 
later pleasant and con- 
trollable. 

Read many books on 
mysticism and hypno- 
tism. 

Received many messages 
from dead statesmen 
regarding state affairs, 
and tried to communi- 
cate these to present 
officials. 

Disliked feminine sex. 

At times arrogant and 
overbearing. 

Very industrious. 

Periodically combative. 

No insight. 

Delusions of grandeur. 

Patient was placed on suprarenal gland and has improved re- 
markably both physically and mentally under this treatment. Most 
of his delusions have disintegrated and constellated about more use- 
ful activities and he is developing more and better insight into the 
previous peculiar experiences. He no longer expresses ideas about 
his mediumistic abilities, and his general attitude is one of cheerful 



16 NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 

industry. He looks upon his psychosis as a peculiar experience 
through which he has passed and recognizes it as an abnormal de- 
velopment. He has lately been discharged as a recovery. 

Case 19. American, male, aged twenty, single, stenographer. 
Mental Diagnosis. Schizophrenia with projection. 
Endocrinosis. Hypothyroidism. 

History. — His father is a psychopath and his mother a timid 
little woman who tried to shield her boys from their father's wrath 
during his excitements. The .patient is the youngest of five sons 
and was always the mother's pet. An older brother also petted 
him a great deal. He was a timid reticent boy and seldom mingled 
with other children unless drawn out by his brothers. He sucked 
his fingers till he was twelve, and slept with his mother until puberty 
or later. Both he and she were leagued together against the father. 
Only once did he oppose his father's will and that time the latter 
chased him off the place with a revolver. 

He reached the eighth grade in school at eighteen. He played 
hooky a good deal and roamed in the woods with another somewhat 
older boy. He admitted masturbation and an attempt at coitus 
when he was twelve. After puberty he grew very shy and avoided 
girls entirely. The brothers were affectionate among themselves 
and liked to wrestle, caress, and kiss each other. It was noticed 
that patient gradually grew resistant to caresses from the brothers 
and particularly from his mother. Toward her he wavered between 
demonstrative affection and irritable aversion. He admitted that 
he had had mother incest dreams, and then immediately denied it. 

After leaving school he went to work in the city, rooming with 
a brother. He liked to imagine himself a character in boy books of 
adventure. He did poorly in his work and finally became very 
frightened, fearing people wanted to kill him. He also spoke of 
voices. He stopped work and hung around home getting untidy 
and sleeping on the floor. He would run away for a few days and 
return disheveled and famished. He could not concentrate on any- 
thing but wandered away into smiling fantasy. He carefully guarded 
his inner life and made a confidant of nobody. After two years in 
a state hospital where he worked on the farm, he was brought to St. 
Elizabeths. 

His mind seems perfectly clear and he gives no evidence now of 
harboring delusions or fantasies or even enjoying his thoughts. He 
sits or lies around the ward and will work but little. He seems fear- 
ful that someone may hurt him but won't explain just what he 
fears. 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 



'7 



He is extremely reticent and will not talk frankly even to his 
family. He lies up and down and cannot be trusted. At every op- 
portunity he escapes. When shut up in well guarded less desirable 
wards he begs to be transferred to an open ward, promising not to 
run away again and then breaks his word at the first opportunity. 
He bitterly resents being confined in an institution, and his main 
idea is to get out. He is keen enough to know what symptoms the 
ward physicians are on the lookout for, and carefully hides them. 

When his parents visit him it is plain to see he prefers his father 
in spite of the past. He begs for money and candy like a child. 

Owing to his refusal to talk with me we tried the word associa- 
tion test. He suspected no ulterior motive here and cooperated, but 
afterwards refused free associations to complex indicators. These 
were eye, lips, mouth, tongue, suck and swallow ; dirty, slimy and 
dog; woods and bushes; jealous, enjoy, lazy, observe, work, sick, 
mother, sleep, dead, marry, pity, yellow, failure, ball, kiss, forget, 
voices, blood, secret, spit, kill and murder. 



Behavior 

" Shut in " type of child- 
hood. 

Truant and " fuge." 

Chronic masturbatof. 

Roamed about by him- 
self. 

Never liked work — had 
numerous jobs but 
never kept them. 

Day dreamer. 

Fear obsessions. 

Previous State Hospital 
record. 

Numerous escapes from 
hospital. 

Dislikes to answer ques- 
tions — secretive. 

Denies hallucinations, but 
there is some evidence 
of their presence. 

Childish in tastes. 

Sits about the ward 
quietly all day with an 
alert facial expression. 



Outline of Case 19 

Physical 

Medium size. 

Skin dark and covered 

with small scales. 
Axillary and pitbic hair 

scanty. 
Extremities cold and 

bluish. 
Sluggish circulation. 
Slow pulse. 

Subnormal temperature. 
Reflexes active. 
Thyroid gland very small. 
Constipation. 
Exophthalmos. 
Hyperhydrosis. 
Awkward gait. 



Laboratory 

Wassermann negative. 

Blood pressure 13 %8- 

Blood uric acid 1.56 mg. 

Blood creatinine 1.48 
mg. 

Blood urea 16.6 mg. 

Thyroid function test: 
Typical hypoglandu- 
lar tolerance. 

Sugar tolerance test! 
Increases sugar tol- 
erance. 



This patient showed very little improvement on small doses of 
thyroid gland but he was somewhat more active physically which 
made him more difficult to handle, and his escapes from the hospital 
were more frequent. 



1 8 NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 

Case 20. American, male, aged thirty-nine, married, laborer. 
Mental Diagnosis. Schizophrenia with projection. 
Endocrinosis. Hypothyroidism. 

History. — A badly deteriorated patient who has been in the hos- 
pital nine years. His history had to be gleaned from the records. 
They state that his family history is negative. He attended school 
from six to fourteen, and failed in the sixth and seventh grades. 
He married at twenty-four and had no children. His wife lived 
with him less than three years. For seven years he had ground 
lenses in an optical shop at low wages, but was discharged because 
he continually quit work early to spy on his wife. He was extremely 
jealous and suspicious of her and accused her of having sexual 
relations with any man in the environment. He rapidly deterio- 
rated, working as elevator man or park laborer until he was com- 
mitted. 

Buzzing voices annoyed him. Some told him to do right, others 
called him vile names. He thought his wife's mother poisoned his 
food and that her brother wanted to kill him. He was restless, sus- 
picious, absorbed in his own thoughts but didn't see why he was 
considered insane. He denied venereal disease or perversions. 

When admitted to our ward almost all his time was spent in 
fantasy. It was both pleasant and unpleasant. He was very erotic, 
securing pictures of women, talking to and kissing them, laughing 
delightedly and taking them to bed with him. He masturbated in 
the toilet many times a day. His most annoying fantasy was that 
he was being "turned over" (probably a passive pederasty idea). 
" Action on the human body is an offense to the law, and I'm a mar- 
ried man." His good days were those in which he was not " turned 
over " so often. 

When these unpleasant thoughts came into his mind he went 
into violent tics, nodding his head up and down, winking his eyes 
and smacking his lips loudly. Frequently he reiterated neologisms 
like "glahba — glahba — glah," in great annoyance. In bed at night 
he went through noisy fights with temptation ending in masturbation 
and sleep. In these struggles he talked of normal coitus, cunnilin- 
gus, anal licking, and bestiality. Sometimes he leaped out of bed, 
his fists fanning the air at some imaginary enemy. 

When he attempted to explain anything his language was so 
unique, with familiar words used to denote special meanings of his 
own that it was practically unintelligible to anyone else. He liked 
to play cards and ball but could only concentrate for a short time, 
being likely to go off into fantasy at any moment. He could not 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 



'9 



concentrate enough to learn even the simplest weaves in occupa- 
tional work. 

After glandular therapy nurses and attendants thought they saw 
some slight improvement. He became neater, quieter, somewhat 
clearer in his talk, had fewer disagreeable fantasies with their ac- 
companying tics, and masturbated less. During the final two 
months he ceased masturbating altogether. There was no marked 
change in his ability to concentrate. He was still unable to learn 
well any task in occupational work. 



Behavior 

Extremely jealous. 

Suspicious of wife's fidel- 
ity. 

Auditory hallucinations. 

Delusions of poisoning. 

No insight. 

Fantastic thinking. 

Extremely erotic. 

Many active facial tics. 

Unable to learn basket 
weaving. 

Converses with unseen 
persons. 

Threatens imaginary ene- 
mies. 

Restless and excited. 

Sometimes polite and 
pleasant. 

Frequent grimaces and 
gestures. 

Enjoys wrestling, base 
ball and other exer- 
cises. 

Daily masturbator. 

Fairly industrious 
ward. 

Noisy at night. 

Frequent smacking 
lips and grunting 
ryngeal sounds. 



o n 



of 
la- 



Outline of Case 20 

Physical 

Slender skeleton. 

Beard slight. 

Xo hair over body. 

Hair of head dry and 
brittle. 

Trophic changes in nails. 

Skin dry and scaly over 
knees and elbows. 

Extremities cold, bluish. 

Papular skin eruption 
over face, neck, and 
chest. 

Mauv pigmented moles 
over body. 

Numerous tics. 

Bradycardia. 

Heart sounds accentu- 
ated. 

Subnormal temperature. 

Slight arteriosclerosis. 

Features of senile decay. 

Anhydrosis. 

Muscles easily fatigued. 



Laboratory 

Wassermann negative. 
Blood pressure 10 %o. 
Blood uric acid 2 mg. 
Blood urea 30 mg. 
Blood creatinine 2.45 

mg. 
Thyroid test: Typical 

hypothyroid reaction. 
Sugar tolerance test: 

Typical hypoglandu- 

lar absorption curve. 



After being placed on regular doses of 1 grain thyroid gland 
twice daily, the patient became more quiet, stopped smacking his 
lips, and stopped masturbating entirely. He also became extro- 
verted, more industrious about the ward and carried out orders ac- 
curately. The skin lesion has melted away, his personal appearance 
has changed in that he is better nourished and is more tidy in habits 
and clothing. 



20 NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 

Case 21. Polish, male, aged twenty-eignt, single, laborer. 
Mental Diagnosis. Schizophrenia with catatonia. 
Endocrinosis. Hypothyroidism. 

History. — A paternal uncle drank and committed suicide. The 
patient was a sickly child. At eighteen he emigrated from Poland 
to the United States and worked for low wages in factories and 
founderies. In the last place it was too hot and he noticed the other 
men were jealous of him because of his good work. He thought his 
food was poisoned and complained to the police. 

To escape from the unpleasant situation he enlisted in the army, 
two months later. Then after two months he was sent to hospital 
because he made silly grimaces and talked to himself. Voices called 
him bad names and he felt everything was all mixed up. Later he 
went into a catatonic stupor and had to be tube fed. 

At first he crouched around all day, eyes closed and fingers in 
ears. He would push away or strike at anyone who disturbed his 
revery. He seemed happy and gave no signs of mental conflict. 

After glandular therapy began he grew more restless and wan- 
dered about as if extroverting in spite of himself. Gradually he 
paid more attention to the environment. A Polish nurse got him to 
answer a few questions in his mother tongue. 



Behavior 

Early delusions of poi- 
soning. 

Occasional silly grimaces 
and gestures. 

Auditory and visual hal- 
lucinations. 

Crouching body attitude, 
eyes closed, and fing- 
ers in ears greater 
part of time. 

Would strike out when 
disturbed. 

No speech activities. 

Occasional catatonic stu- 
por with tube feeding. 

Negativistic and waxy 
flexibility. 

Untidy — pays no atten- 
tion to condition of 
clothing. 

Occasionally restless 
walking to and fro. 

Admires himself in mir- 
ror several times daily. 

Swallows food in large 
bolus without chewing. 

Kicks attendants. 



Outline of Case 21 

Physical 

Medium sized skeleton. 

Pale smooth skin. 

Entire chest and abdo- 
men covered with long 
matted hair. 

Mammary glands en- 
larged. 

Abdomen very promi- 
nent. 

Muscles universally weak 
and flabby. 

Ligamentum nuchae over 
developed. 

Lips large pouting and 
in constant motion. 

Mitral systolic murmur. 

Pulse slow, weak and ir- 
regular. 

Pupils small — react slug- 
gishly. 

Corneal reflexes reduced. 

Reflexes all sluggish. 

Anhydrosis. 



Laboratory 

Wassermann negative. 

Blood pressure 14 %o- 

Blood uric acid 2.32 mg. 

Blood urea 18 mg. 

Blood creatinine 3.50 
mg. 

Thyroid test: Hypo- 
glandular type. 

Sugar tolerance test: 
Low initial blood 
sugar" with rapid ab- 
sorption. 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 21 

By June he no longer hung his head or closed his eyes and ears. 
He would do some basket weaving or make a bed and obey orders 
generally. He looked more alert, did not fight people off,' and told 
the Polish nurse he wondered why he was here. 

He became more active during the test, began rapid stereotyped 
movements of the lower extremities and walked around a great deal 
more than usual. After being placed on one grain of thyroid gland 
three times daily, he began to talk some Polish and swear in Polish 
at his attending nurse. He had a peculiar type of behavior when 
extroversion began in that he would often awaken from his intro- 
verted state, with wide open eyes staring about the ward as though 
surprised at his surroundings. Soon he began to make baskets, 
polish floors, shake hands, and exchange greetings. General men- 
tal and physical improvement has been remarkable. 

Case 22. American, male, aged thirty-two, single, no occupation: 
Mental Diagnosis. Schizophrenia with introversion. 
Endocrinosis. Hypothyroidism. 

History. — His parents, older brother and sister are living and 
well. There is no insanity in direct line but some cousins are insane. 
He was always quiet and shut in. In school he was bright, once even 
skipping a grade, but he left when in the sixth grade because the 
teacher unjustly accused him of throwing a spitball. He worked in 
the family grocery store for three years, then as a machinist. 

At seventeen he quit work and remained at home for fifteen 
years until admitted into the hospital. In the beginning he helped a 
little around the place and went with one boy friend. He never 
asked for money and cared nothing for theaters or movies, but read 
omnivorously, having apparently no preferences. 

Six years ago he refused to eat for a while and was confined to 
bed. Since then he has done no work whatever, except cook his 
own food, about which he was very finical. He gradually grew un- 
tidy, let his hair grow down to his shoulders, refused to change his 
clothes or bathe, became more irritable, smashed dishes and threat- 
ened his family. 

In the hospital he submitted to authority and was bathed, shorn, 
and dressed neatly. He complained of feeling cold and weak and 
said he had worn his hair long as a protection again the cold. He 
jealously guarded his inner life and quietly resisted any question- 
ing. He admitted he had always found it difficult to make conver- 
sation and had been bashful, and that his thoughts were not unpleas- 
ant. He had no plans and took each day as it came. 



22 NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 

He lay and sat around the ward, refusing to join in any occupa- 
tion, saying he felt tired. Occasionally he would talk to himself 
about having to support his family and not earning enough. In fan- 
tasy he compensated for his fifteen years sponging on them. He 
had a strong sexual taboo, refusing any information, but stated 
once that he considered night emission shameful, just like urinating 
in bed. His behavior indicated no hallucinations or delusions be- 
yond his seeming belief that he had supported the family. 

Coincident with the beginning of glandular therapy he consented 
to try basket weaving. He showed more energy and stopt lying 
on his bed by day. He became more cheerful, showed some interest 
in his work and did it without urging. He still kept by himself, re- 
fused to mingle with other patients, and talked to himself, resenting 
his family's sending him to the hospital and depriving him of free- 
dom and the opportunity to earn money. The earning of money 
seemed to be his chief preoccupation. 



Outline of Case 22 

Physical 

Slender type of skeleton. 

Pale — slightly scaly skin. 

Few long hairs about 
nipples. 

Scanty body hair and 
none over the face. 

Reflexes slightly subnor- 
mal. 

Extremities, damp, cold 
and cyanotic. 

Pulse 78. 

Mitral systolic heart 
murmur. 

Subnormal temperature. 

Fatigue without energy 
expend. 

Chronic constipation. 



Laboratory 

Wassermann negative. 

Blood pressure 12 94o. 

Blood uric acid i.6omg. 

Blood urea 16 mg. 

Blood creatinine 3.05 
mg. 

Thyroid test: Hypo- 
glandular reaction. 

Sugar tolerance test: 
Hypoglandular type 
of absorption. 



Behavior 

Shut in type of boyhood. 

Good scholar. 

Omnivorous reader. 

Periodic abstinence from 
food. 

Untidy in person and 
clothing. 

Bashful — day dreaming 
makeup. 

Well developed sexual 
taboos. 

Slight evidence of hal- 
lucinations. 

No delusions. 

Quiet and motionless 
usually. 

Assists somewhat i n 
ward duties. 

Talks sometimes to him- 
self. 

Answers questions cor- 
rectly and converses 
connectedly. 

Mild and obedient. 

Shuns society as much 
as possible. 

This case was diagnosed dementia praecox, hebephrenic type 
and had been idle and unproductive for six years. During the thy- 
roid test the patient began work and has shown notable improve- 
ment both mentally and physically. He has been on thyroid gland 
2 grains daily for two months during which time he has been ener- 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 



23 



getic, works without being invited to, habits are neater than before, 
pays more attention to personal appearance, sleeps better and has 
.gained in weight. 

IV. Discussion 

As is usual in endocrine symptomatology many of the above 
physical signs are interpreted as indicating pluriglandular involve- 
ment, but it was thought advantageous to limit the general diag- 
nostic headings as far as possible to single term expressions repre- 
senting the main glandular picture. 

In Table I, where the laboratory findings are arranged accord- 
ing to the type of endocrinosis, it is noted that as in other groups of 
mental diseases (12) there are very few deviations from the aver- 
age content in uric acid urea and creatinine ; with the possible excep- 
tion of the urea which in general has given higher values through- 
out ; but in the sugar tolerance and thyroid tests there is an indication 
that we have valuable diagnostic aids in determining the type of 
glandular response. 

Table I 
Results of Laboratory Examinations 





Mg. per 100 c.c 


Blood 








Case 


Uric 
Acid 


Urea 


Creati- 
nine 


Sugar Tolerance 


Thyroid Test 


Endocrinosis 


4 


1.80 


14 


1-55 


Increased 


Hypoglandular 


Hypothyroidism. 


5 


1. 45 


22 


2.30 






** 


" 


6 


O.80 


16 


1.50 






*' 


" 


7 


2.00 


18 


3-00 




• 


" 


" 


10 


I.40 


22 


1.60 




; 




" 


11 


1. 00 


24 


3-6o 






None 


" 


14 


0.90 


26 


2.00 






Hypoglandular 


" 


15 


0.80 


16 


1.20 








* 


• 


19 


1.56 


18 


1-45 








' 


" 


20 


2.00 


30 


2-45 








* 


" 


21 


2.20 


18 


3-50 








1 


" 


22 


I.60 


16 


3-oo 








• 


" 


2 


I.50 


36 


2.82 








• 


Polyglandular. 


17 


1. 00 


22 


2.50 








' 


Hypopituitarism. 


12 


1.80 


18 


1.50 


Atypical 




* 


Dispituitarism. 


3 


1. 00 


16 


1.20 


Increased 


" 


Periodic hypo- 
adrenia. 


13 


1.83 


IS 


2.86 




None 


Periodic hypo- 
adrenia. 


9 


1.40 


16 


2.50 


Prolonged curve 


Hypoglandular 


Mixed thyro- 
trophic. 


1 


2.60 


36 


2.50 




Contraindicated 


Exophthalmic 
goitre. 


8 


1.80 


27 


3-20 




Hyperglandular 


Hyperthryoidism 


16 


2.40 


20 


1.92 


it 11 






18 


0.8s 


30 


2.60 


• 1 11 


" 





Considering the sugar tolerance test there is the "prolonged 



2[ 



NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 



curve " or delayed absorption reaction in the four hyperthyroid 
patients (cases I — 8 — 16 — 18) only one of which has an exophthal- 
mic goitre. The only other hyperglandular sugar response is a 
pluriglandular condition (Case 9). Figure one illustrates two of 




Secona Hour 



Third Hour 



Fig. 1. Hyperglandular sugar tolerance curves. 

Interrupted line = Normal. 

Upper curve = Hyperthyroid with manic reaction (shows initial fright) 

(Case 8). 
Lower curve = Exophthalmic goitre (Case 1). 

these hyperglandular curves which are quite typical of the response. 
The upper curve shows a high sugar content at the first determina- 
tion which has been a frequent finding in those patients responding 
to the situation with extreme fear (13). In both curves the blood 
sugar is still high at the second and third hours. 

In the twelve cases of clinically diagnosed hypothyroidism the 
sugar tolerance is increased in each, and this hypoglandular reac- 
tion is also present in the two hypoadrenias (cases 3 and 13), one 
hypopituitary (case 17), and in the one polyglandular type (case 
2). In the case (12) of epilepsy with pituitary disturbance the 
curve is atypical being high at the first hour and dropping rapidly. 
Figure 2 illustrates two of the average hypoglandular or increased 
tolerance curves. Although the number of cases is small from the 
above findings one is certainly justified in giving the sugar tolerance 
test an important place in the analysis of these often difficult cases. 
Wilson (14) found the test very useful in indicating the value of 
x ray treatment in hyperthyroidism. It was proven experimentally 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 



25 



by Janney and Isaacson (15) that hypoglycemia results from hypo- 
endocrine functions and develops regularly after thyroidectomy. 
Low blood sugar values have been reported in other hypoendocrine 
diseases. 



Blood 

Sugar 

1- 



o.*» 



■ a -sfr 



O.i.3 




Second Wnr 



Fig. 2. Typical hypo-glandular" sugar tolerance curves. 

Interrupted line = Normal. 

Upper curve = Hypoadrenia with schizophrenia (Case 3). 

Lower curve = Hypothyroidism with projection (Case 4). 

There are certain contraindications and conditions which may 
invalidate the test by affecting the absorption rate; some of those 
are irritable stomach in neurotic states (persistent vomiting of the 
sugar solution), grave gastroenteric diseases (producing delayed 




Fig. 3. Thyroid Test: Hyperglandular curves. 

Upper curve = Hyperthyroidism with manic features (Case 8). 

Lower curve = Hyperthyroidism with schizophrenia (paranoid) (Case 16). 



26 



NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 



absorption) and extensive ulcerations or adhesions interfering with 
normal peristalsis. 

The thyroid tests are of the hyperglandular type in three of the 
four hyperthyroid cases, the test being contraindicated in the other 
because of the usual extreme acceleration in Basedow's disease 
(Fig- 3) gives two examples of the hyperglandular reaction with 
the pulse remaining high for two days after terminating the admin- 
istration of the test capsules. 



: pulse 


i 1st da; 


: 2nd. 

; 


day 


i 3rd. 

: 


day 


: 4 th. day 

i 


j 5th. 

» 


day 


: 6th. day 

: 




I 150 






















1 140 






















s 130 






















I 1£0 






















■ no 






















i 100 








: 90 






















I 60 








» 




: 70 






















s 60 






















; "50 




















1 

1 



Fig. 4. Thyroid Test: Hypo-glandular curves. 



i = Case 17- 
2 = Case 14- 



-Hypopituitarism with schizophrenia. 
-Hypothyroidism with schizophrenia. 



In the normal individual the thyroid feeding on the day when 
the largest capsules are given, stimulates the thyroid and through it 
the heart rate, so that we get the increase in pulse rate which being 
due to the administered extract comes back to normal the day after 
the capsules are stopped. However, if the individual is in some de- 
gree hyperglandular according to susceptibility and the amount of 
circulating hormone the pulse rate will increase early in the test and 
reaches a high level (often high enough and with associated phe- 
nomena to necessitate termination of test) which persists for two 
or three days after administration of last capsules. 

The hypoglandular constitution, on the other hand, scarcely re- 
acts at all, and in many cases practically no change is seen in the 
pulse rate; the tissues are sluggish and in need of acceleration. 
Figure 4 illustrates two hypoglandular curves (Cases 17 — 14) to 
which general type eleven of the twelve hypothyroid cases belong. 
The remaining hypothyroid patient because of some delusion re- 
fused to cooperate (Case 11). The remaining six cases (hypo- 
glandular and mixed types) excepting one (Case 13) in which there 
was a contraindication give the hypoglandular reaction. 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 27 

In many of the sluggish and apathetic individuals with intro- 
versions a change in behavior often with marked temporary im- 
provement occurs during the three day feeding of thyroid, and it 
has been discovered that regardless of the main type of hypofunc- 
tion, the preliminary administration of thyroid gland over a period 
enhances the action of the pituitary, suprarenal or other glands to 
be given later (16). 

The principal contraindications of the thyroid function test are 
frank Basedow's disease, manic or anxiety conditions, with rapid 
heart and great excitability, and advanced valvular heart diseases. 

In Table II where a comparison is made of the psychoses, and 
endocrinoses with duration of treatment and results, it is seen that 
although the selection of cases was made on the endocrine basis and 
includes several types, the mental construction is that of schizo- 
phrenia in some form. 

Phillips (17) found twelve per cent, of two hundred patients 
with mental disease to be hyperthyroid, seventeen of the number 
suffered from an affective reaction type. In our small group the 
hyperthyroid patients were all schizophrenics with projection and 
paranoid features. Phillips feels that hyperthyroidism is usually 
associated with states of excitement, agitation, etc., while hypothy- 
roidism is more often found in states of apathy and introversion, 
as compared with the usual reports on glandular therapy the periods 
of treatment are very short, and the recorded results which are 
based on them should be interpreted in terms of possibilities rather 
than in permanent achievements. 

The psychoses of the four mental recoveries were of short dura- 
tion, but were unmistakable schizophrenia (two of which were 
paranoid in type). 

Eight patients with psychoses ranging from nine to two and one 
half years in duration are benefited physically and mentally. Seven 
patients are improved physically, but show changes in behavior not 
recorded as improvement. Two patients, who did not receive treat- 
ment, for reasons mentioned in the history, are not changed physically 
or mentally and one improved somewhat mentally, but not physically. 

It is well to state that the above physical and mental results, 
changes in behavior, etc., are not recorded on the opinion of one 
individual, but are taken from the written unanimous reports of 
three physicians, an occupational therapist, and two trained nurses. 



28 



NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 



Table II 
Comparing Duration of Psychoses with Treatment and Results 







Approxi- 




Duration 


Results 


Case 


Psychosis 


mate Dura- 
tion 


Endocrinosis 


Treatment 


Physical 


Mental 


I 


Schizophrenia 
(projection) 


9 years 


Hyperthy- 
roidism 


Operative 


Improved No change 


2 


Schizophrenia 
(projection) . 


io 


Polyglandu- 
lar 


None 


None None. 


3 


Schizophrenia 
(circular) 


5 " 


Periodic hy- 
poadrenia 


i^ months 


Improved 


None. 


4 


Schizophrenia 
(projection) 


2 " 


Hypothy- 
roidism 


5 


Improved 


Improved. 


5 


Schizophrenia 


9 " 


Hypothy- 


4 


Improved 


Improved. 




(projection) 




roidism and 
hypoa- 












drenia 








6 


Schizophrenia 
(projection) 


8 " 


Hypothy- 
roidism 


4i " 


Improved 


Improved. 


7 


Schizophrenia 
(introver- 
sion) 


3 " 


Hypothy- 
roidism 


4i " 


Improved 


Improved. 


8 


Schizophrenia 
(affective 
features) 


t\ " 


Hyperthy- 
roidism 


3 


Improved 


No change. 


9 


Schizophrenia 
(paranoid) 


5 " 


Mixed thyro- 
trophic 


i| " 


None 


Improved. 


io 


Schizophrenia 
(projection) 
on Moron 
basis 


i " 


Hypothy- 
roidism 


4 


Improved 


Recovery 
(dis- 
charged) 


ii 


Schizophrenia 


ii " 


Hypothy- 
roidism 
and hypoa- 
drenia 


None 


None 


None. 


12 


Schizophrenia 
(defective 
epileptic 
basis) 


4 " 


Dispituitar- 
ism 


2h " 


Improved 


None. 


13 


Schizophrenia 
(affective 
features) 


A " 


Periodic hy- 
poadrenia 


si " 


Improved 


Improved. 


14 


Schizophrenia 
(projection) 


7 " 


Hyperthy- 
roidism 


4 




No change. 


15 


Schizophrenia 
(paranoid) 


2 " 


Hypothy- 
roidism 


4 




Recovery 
(dis- 
charged) 


16 


Schizophrenia 
(projection) 


2 " 


Hyperthy- 
roidism 


2 " 




None. 


17 


Schizophrenia 
(projection 
Moron 
basis) 


I 

• 


Hypopitui- 
tarism 


4 




Recovery 
(dis- 
charged). 


18 


Schizophrenia 
(paranoid) 


l| " 


Hyperthy- 
roidism 


3h " 




Recovery 
(dis- 
charged) . 


19 


Schizophrenia 
(projection) 


3 " 


Hypothy- 
roidism 


2\ " 




None. 


20 


Schizophrenia 
(projection) 


io " 


Hypothy- 
roidism 


3 




Improved. 



NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 



29 





Psychosis 


Approxi- 
mate Dura- 
tion. 


Endocrinosis 


Duration 
Treatment 


Results 




Case 


Physical 


Mental 


21 
22 


Schizophrenia 
(catatonia) 

Schizophrenia 
(introver- 
sion) 


4 " 
6 '* 


Hypothy- 
roidism 

Hypothy- 
roidism 


3i " 

2 


» 





V. Conclusions 

i. Since the activities of the nervous system, and particularly 
those of the autonomic divisions are closely associated with endo- 
crine functions, one must suppose that maladjustments of the in- 
dividual to certain situations will produce a response in the glands 
varying according to the strength of the impulse, development, vigor, 
and physiological activity and balance existing between the com- 
ponent parts of the gland and on the other hand, original defects in 
these glands connected as they are with external form, and visceral 
and metabolic functions must produce limitations in the action sys- 
tems and peculiarities of behavior. 

In many cases of mental disease, regardless of the priority of 
the mental disturbance or of the endocrine imbalance there is cer- 
tainly a circle of abnormality established, the arcs of which are com- 
posed of both groups of factors. 

2. In glandular disturbances the effects are due to a change in 
rate of normal function, and as thyroid extract is an accelerator 
principle, the stimulating action of which is intracellular, and the 
effect of which is not felt in any particular set of organs or tissues 
alone, it is reasonable to suppose that its administration in hypo- 
glandular types accelerates the organism in general, rendering intro- 
version more difficult and aiding the application of psychotherapy. 
This is well illustrated in several of our cases in which changes in 
behavior and improvement began simultaneously with the thyroid 
testing experiments. 

3. For every case manifesting profound glandular disturbance 
there are doubtless dozens that show only little signs, and it is in 
these cases that a psychological or chemical attempt to break one of 
the arcs of the circle is more likely to result in success. 

4. Both the sugar tolerance test and the thyroid function test 
have been found extremely valuable in differentiating and in sizing 
up the hypo- and hyperglandular types, in which often instead of a 
profound, easily recognized disturbance, only the little signs may 
show. It is in these that scientific application of glandular therapy 
has its earliest and best opportunity. 



3Q NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 

5. Occupational therapy, when applied by a therapist well trained 
in observing patients with mental disorders has been found of value 
in an experiment of this sort, not only from a therapeutic stand- 
point, but as an early indicator of variations in behavior. The 
attitude of the patient, fluctuations in interest and attention, and 
signs of improvement are early recognized by apt workers in this 
field. 

6. In conclusion we wish to express our thanks to Miss Walker, 
the occupational therapist, and to the nurses who aided in this in- 
vestigation. Our heaviest obligations are to Dudley W. Fay, Ph.D., 
who is responsible for the mental analyses and who is soon to pub- 
lish a separate thesis on the mental constructions of these patients. 

Government Hospital for the Insane 

BIBLIOGRAPHY 

1. Cushing, H. Psychic Disturbances Associated with Ductless Glands. 

American Jour. Insanity, Vol. 69, p. 965 (1913). 

2. Delgado, H. F. The Psychology of Insanity. Chronica Medica, Vol. 

36, p. 675, Sept., 1919. 

3. Turro, Ramon. Emotion and Endocrinology. Siglo Medico, Madrid, 

Vol. 66, p. 3444, Dec. 13, 1910. 

4. Rossi, S. C. Suprarenal Insufficiency and Manic Depressive. Psychoses 

Anales de la Facultad de Medicina (Madrid), Vol. 4, p. 12, Dec, 1919. 

5. Laignel-Lavastine, M. The Internal Secretions and the Nervous Sys- 

tem. Nervous and Mental Disease Monograph Series No. 30. 

6. Janney, N. W., and Isaacson, V. I. A Sugar Tolerance Test. Jl. A. 

M. A., Vol. 70, No. 16, p. 1 131. 

7. Bang, Ivar and Hatlehol, I. K. Microchemical Method of Estimating 

Dextrose. Biochem. Zeitschr.. 87, 264-72, 1918. 

8. Harrower, H. Clinical Results With a Method of Testing Thyroid Func- 

tion. Medical Record, 96, 18, p. 722. 

9. Folin and Wu. Jour. Biol. Chem., 38, 81, 1919. 

10. Folin. Idem, 11, 527, 1912. 

11. Folin and Wu. Idem, 38, 98, 1919. 

12. Weston, P. G. Analyses of Blood of Insane Patients. Am. Arch. 

Neurol, and Psychiat. (Chicago), 3, No. 2, p. 147, Feb., 1920. 

13. Lewis, N. D. C. Personal investigation of blood reducing substances 

during emotions, soon to be published. 

14. Wilson, E. R. Blood Sugar Tolerance as an Index in the Early Diag- 

nosis and Roentgen Treatment of Hyperthyroidism. Jl. Lab. Clin. 
Med., 5, No. 11, 1920. 

15. Janney and Isaacson. Arch. Int. Med., 22, 160, 1918. 

16. Claude, H., and Bernard, S. Glandular Functioning. Bulletins de la 

Societe Medicale des Hopitaux. Paris, 43, No. 37, Dec. 19, 1919. 

17. Phillips, N. R. Goitre and the Psychoses. Jour. Mental Science (Lon- 

don), 65, 271, Oct., 1919. 

In addition to the above references the following will be found of interest. 

Jelliffe and White. Text Book of Nervous and Mental Diseases, third edi- 
tion, 1919. Chapt. Ill, 197. 

Leopold-Levi and de Rothschild. La petite Insuffisance Thyroidienne et son 
Traitement. Pub. I. Doin et Fils, Paris, 1913. 

Campbell, H. Exophthalmic Goitre. Clinical Journal, 44, 329, 1915. 

Blair, Bell. The Internal Secretions and Female Characteristics. Proc. 
Royal Soc. Med., 6, 74, 1913. 



ENDOCRINE IMBALANCE AND MENTAL DISEASE 31 

Plummer, W. A. Blood Picture in Exophthalmic Goitre. Minnesota Medi- 
cine, 2, 9, p. 330, Sept., 1919. 

Glassburg, J. A. Headache and Dyspituitarism in the Light of Therapeusis. 
Medical Record, 96, II, Sept. 13, 1919. 

Kendall, E. C. Isolation of the Iodin Compound which occurs in the Thy- 
roid. Jl. Biol. Chem., 39, 125, Aug., 1919. 

Sajous, C. E. de M. Curative Versus Symptomatic Treatment of Exoph- 
thalmic Goitre. Medical Record, 96, 13, p. 536, Sept. 27, 1919. 

Auer. The Physical Manifestations of Disease of the Glands of Internal 
Secretion. Am. Journ. of Insanity, p. 405, 1914. 

Marine. The Evolution of the Thyroid Gland. Bull. Johns Hopkins Hosp., 
24, 135, I9I3- 

Kendall, E. C. The Function of the Thyroid-Parathyroid Apparatus. J, A. 
M. A., 66, 11, p. 811, March 11, 1916. 

Wechsler", I. S. The Psychoneuroses and Internal Secretions. Neurol. 
Bull., 2, 199, May, 1919. 

Barham, G. H. Insanity with Myxedema. Jl. Mental Science, 58, 226, 1912. 

Uyematsu, S. A Case of Myxedematous Psychosis. Am. Arch, of Neurol. 
Psychiat., Chicago, 3. March, 1920. 

Abrahamson. A Study of One Hundred Selected Cases of Pituitary Dis- 
ease. Jl. A. M. A., 69, 4, p. 281. 

Gutman, J. The Ductless Glands and Constitutional Diagnosis. Medical 
Record, 97, 14, Apr. 3, 1920. 

Prior, G. P. U. Mental Cases of Endocrine Considerations. Jl. Mental 
Science, London, 66, 272, p. 23, Jan., 1920. 

Hertz, J. J. Medical Aspects of Endocrinology. Med. Record, 97, 13, p. 
511, March 27, 1920. 

Janney, et al. The Endocrine Origin of Muscular Dystrophy. Arch. Int. 
Med., 21, 188 (Feb.), 1918. 

Woodbury, M. S. A Comparison of Methods for Determining Thyrotoxi- 
cosis. Jl. A. M. A., Vol. 74, No. 15, p. 997. April 10, 1920. 

Troell, A. The Diagnosis of Exophthalmic Goitre. Hygiea (Stockholm), 
Jan. 31, 1920, 82, No. 2, p. 33. 

Juarros, C. Hyperthyroidism and Pseudohysteria. Plus Ultra (Madrid), 
Sept.-Oct., 1919, Vol. 3, No. 15-16. 

Bandler, S. W. The Balance Between the Endocrines, etc. Med. Record, 
Vol. 97, No. 16, April 17, 1920. 

Harrower, H. R. The Principles of Adrenal Support. Medical Record, 
Vol. 98, No. 10, p. 391, Sept. 4, 1920. 

Pardee, I. H. Pituitary Headaches. Arch. Int. Med., 23, No. 2, p. 174, Feb. 
IS, 1919. 

Leiner, J. H. The Little Signs of Thyroid Disturbances. Medical Record, 
Vol. 96, No. 3, p. 99, July 19, 1919. 

Tucker, B. R. Role of Pituitary Gland in Epilepsy. Am. Arch, of Neurol, 
of Psych. (Chicago), Vol. 2, No. 2, p. 192. 

Harrower, H. R. An Hypothesis of Harmone Hunger. Medical Record, 
Vol. 96, No. 7, Aug. 16, 1919. 

Loeffler", W. Basal Gas Exchange in Disturbances of the Organs of Internal 
Secretion. Zt. Klin. Med., 87, 280, 91 (1919). 

Sezary, A. Suprarenal Insufficiency. Presse Medicale, Paris, Vol. 27, No. 
53. P- 553. Sept. 22, 191 1. 

Engmann, M. F. The Skin a Mirror to the System. Jl. A. M. A., Vol. 73, 
No. 21, p. 1565, Nov. 22, 1919. 

Fici, V. Multiple Endocrine Disturbances. Riforma Medica, Naples, Sept. 
13. 1919, 35. No. 37, p. 778. 

Means, J. H, and Aub, J. C. Basal Metabolism in Hyperthyroidism. Arch, 
of Int. Med., Oct. 15, 1919, 24, No. 4, p. 404. 

Leuders, C. W. Use of Laboratory Methods in Diagnosis of Early Hyper- 
thyroidism. Arch. Int. Med., Oct. 15, 1919, 24, No. 4, p. 432. 

Smith, F. H. Studies on Hyperthyroidism. Jl. A. M. A., Vol. 73, No. 24, 
p. 1828, Dec. 13, 1919. 



32 NOLAN D. C. LEWIS AND GERTRUDE R. DAVIES 

McCaskey, G. W. Differential Diagnosis of Hyperthyroidism. N. Y. Med. 

Journ., no, No. 15, Oct. II, 1919. 
Friedmen, C. D. The Internal Secretions. Med. Record, Vol. 96, No. 23, 

p. 916, Dec. 6, 1919. 
Timme, W. Endocrinologic Aspects of Some Neurologic Conditions. Am. 

Arch. Neurol, and Psychiat., Chicago, June, 1920, 3, No. 6. 
Porak, R. Gland Extracts in Differential Diagnosis. Annales de Medicine, 

Paris, Jan., 1920, 6, No. 6, p. 469. 
Apert, E. Organotherapy for Children. Presse Medicale, Paris, May 29, 

1920, 28, No. 35, P- 34i- 
Davis, T. K. Endocrine Defects and Mental States. Am. Arch, of Neurol. 

and Psychiat., Chicago, Aug., 1920, 4, No. 2, p. 185. 
McCready, E. B. Organotherapy in Certain Diseases and Conditions of 

Childhood. Med. Record, Vol. 96, No. 13, p. 529, Sept. 27, 1919. 
Lescohier, A. W. The Present Aspects of Endocrinology. Medical Record, 

Sept. 27, 1919, 96, 13, p. 532. 



EPIDEMIC ENCEPHALITIS SIMULATING MYASTHENIA 

GRAVIS 1 - - 

Three Cases of Epidemic Encephalitis Presenting the Clini- 
cal Syndrome of Myasthenia Gravis. Preliminary 
Anatomical Report of Sections Obtained 
from the Brain in One of the Cases 

By Morris Grossman, M.D. 

ADJUNCT NEUROLOGIST TO THE MOUNT SINAI HOSPITAL AND THE MONTEFIORE 

HOME AND HOSPITAL 

The following three cases are reported because they presented 
unusual difficulties in the differential diagnosis between epidemic 
encephalitis and myasthenia gravis despite the advantage of careful 
study and hospital observation extending over a period of many 
weeks. If they had not occurred during an epidemic of encephalitis, 
they would most likely have been diagnosticated as cases of 
myasthenia gravis. 

Case i. M. A., female, 53, married, housewife, born in Russia, 
entered the hospital January 4, 1921. 

Family History. — Has no bearing on the present illness. 

Past History. — She does not remember any diseases during 
childhood. She has been married for the past 30 years. She gave 
birth to six children, and had no miscarriages. She has had difficulty 
in hearing for the past 30 years. Twelve years ago she had a 
postpartum infection. Five years ago she suffered from what was 
said to be a right sciatica. 

Present History. — Her present illness began six weeks ago with 
abdominal cramps and pain along the spine. For the next two 
days the patient noticed blood in her stool. Five weeks ago the 
patient began to have diplopia. There was also aggravation of a 
chronic headache from which she had suffered for a long time ; this 
was now associated with tinnitus and vertigo. There was no nausea or 
vomiting. Four weeks ago she noticed drooping of her left eyelid ; 
at the same time the diplopia and vertigo disappeared. Three weeks 
ago ptosis of the right lid occurred. She was easily fatigued and 
there was a general sense of weakness which incapacitated her. 
She can masticate her food, but is easily fatigued during the act. 
There has been no difficulty in swallowing nor has there been any 

1 From the Neurological Service of the Mount Sinai Hospital. New 
York City, New York. 

2 Presented before a clinical conference of the Neurological Staff of 
The Mount Sinai Hospital ; January 17 and March 14, 1921. 

33 



34 MORRIS GROSSMAN 

regurgitation of fluids through the nose. For the past two weeks 
she has had difficulty in raising her arms and in moving her legs. 
This weakness is more marked on the left side. She cannot walk 
or stand, and is unable to raise herself from a recumbent to a sitting 
position. She has had frequent attacks of chilliness but no fever. 
There are no other complaints. 

Summary of Her History. — She had difficulty in hearing for the 
past 30 years. Postpartum infection 12 years ago. Right sciatica 5 
years ago. Abdominal cramps, pain along the spine, blood in the 
stools for two days ; diplopia, headache, vertigo and tinnitus six 
weeks ago. Ptosis of the left lid four weeks ago, ptosis of the 
right lid three weeks ago ; and weakness in the muscles of the neck, 
trunk, and extremities associated with marked fatigue for the past 
two weeks. 

Physical Examination. — She is a well-developed and well-nour- 
ished woman. Her general medical examination is negative. She 
appears fairly intelligent, is well oriented, and cooperates in the 
examination. Her pupils are central, equal, regular, and react 
promptly to light. Although little movement takes place when she 
attempts to converge, her pupils respond. There is practically a 
complete bilateral external ophthalmoplegia. The eyelids are ptosed, 
the right being more marked than the left. The fundi are normal. 
The visual fields roughly tested do not show any contraction. There 
is slight atrophy of the left masseter and temporal muscles. The 
sensory fifth is normal. Hearing is diminished on both sides, but the 
patient states that that has been present for many years before the 
present illness. The muscles of the neck, shoulder girdles, arms, 
forearms, trunk, pelvis and lower extremities show marked weak- 
ness. This is more marked in the axial muscle groups. The patient 
is unable to hold up her head, nor can she raise herself from a 
recumbent to a sitting position. She can raise her arms not quite 
to a right angle, but is unable to hold them in that position ; likewise 
the limbs can be raised from the bed but can not be held up for more 
than an instant. There is a moderate increase in the activity of 
all of the deep reflexes of the upper and lower extremities on both 
sides. The abdominal reflexes can not be elicited, probably on 
account of a lax abdominal wall. The plantar reflexes are active. 
No Babinski is present. There is no tremor or ataxia in either the 
upper or the lower extremities. Touch, vibratory, muscle and 
joint sensibility, pain and temperature senses are not disturbed. Her 
blood pressure was 145 systolic and 85 diastolic. The urine showed 
a trace of albumin and an occasional hyaline cast. The Wassermann 
reaction in the blood and spinal fluid is negative ; 8 c.c. of spinal 
fluid was removed ; the pressure was not increased ; 8 cells, lympho- 
cytes, were found to the cubic millimeter ; the globulin content of the 
fluid was normal. The blood chemistry was reported by Dr. Book- 
man to be normal. X-ray examination of the chest on two different 
occasions failed to show any abnormality ; no enlargement of the 
thymus could be detected. Electrical examination of the muscles 
done by Dr. Harris, on three different occasions, showed a slight 



EPIDEMIC ENCEPHALITIS 35 

quantitative increase for the galvanic current, but no myasthenic 
reaction. 

Clinical Course While Under Observation. — On January 7, the 
patient complained of difficulty in swallowing and in breathing when 
she would lie down. The throat was congested but the soft palate 
moved freely. On January 10, the right pupil was noted to be 
larger than the left, there was slight movement of the right eyeball 
to the right. All other movements of the eyeballs were absent. 
Ptosis of the right eyelid had increased. Weakness of the muscles 
of the left shoulder girdle was more marked than in those of the 
right. Slight atrophy of the anterior part of both deltoids was 
present, but there were no fibrillary tremors. The deep reflexes 
were all present and equally hyperactive on both sides ; there was 
no tendency to exhaustion of the reflex at the knee after repeated 
stimulation. A doubtful Babinski, inconstantly present, was elicited 
on both sides. On January 12 the power in the muscles seemed 
to be slightly improved, and the patient was able to swallow with 
less difficulty. From this date until the time she left the hospital 
on the 20th of February, there was a gradual improvement in the 
strength of the muscles of the neck, trunk, upper and lower ex- 
tremities. The neurological examination at that time showed that 
the patient was able to hold up her head well, and she could raise 
herself from a recumbent to a sitting position. She was able to 
walk without assistance. She can raise her arms to a right angle 
and keep them up for some time. The grasp in both hands is poor, 
and the patient has difficulty in dorsiflexion of both feet. There is 
a marked ptosis of both lids. The right pupil is larger than the left, 
both however react well to light and on attempt at convergence. 
The external ophthalmoplegia is almost complete on both sides. She 
still has slight difficulty in swallowing. All the deep reflexes are 
very active on both sides. One hundred consecutive taps of the 
tendons at both knees failed to show any diminution in the activity 
of the knee jerks. A doubtful Babinski and Oppenheim response 
is inconstantly obtained on the right side. With the exception of 
the external ophthalmoplegia, the muscles of the patient are grad- 
ually getting stronger. 

Case 2. I. G. Male. 53. Operator, born in Russia. Entered the 
hospital December 23, 1920. His chief complaints were double 
vision, and weakness in the left arm and both legs. 

Family History. — His father and mother died of causes unknown 
to him. One brother died of pulmonary tuberculosis at the age of 
17; two brothers and five sisters are living and in good health. 

Marital History. — He has two children living and well at the 
present time. His wife had one miscarriage. 

Past History. — He does not remember having had any of the dis- 
eases of childhood. Four years ago he had an attack of "grippe,"" 
during which he had retention of urine of 36 hours. For many 
years he has had slight burning and frequency of urination. 

Present History. — About three weeks before he entered the hos- 
pital, the patient noticed that he had double vision; the objects that 



3 6 MORRIS GROSSMAN 

he saw were placed next to each other in the lateral plane. One 
week later, while walking, his knees suddenly gave way and he 
would have fallen but for the support received from a physician 
who was examining his eyes at the time. The following day the 
patient noticed that his left arm and hand had become weak. This 
weakness progressed so that he was unable to lift a two-pound 
package. One day later he noticed that he was unable to flex the 
middle finger of his left hand. About one week before admission to 
the hospital, the patient noticed that the upper lid of his right eye 
became swollen, and at the same time he was having a biting pain 
in the right nostril. He also noticed at this time that he swayed 
when walking. Four days before admission his knees gave way 
while going up two steps leading from the street to his house, and 
he fell down. The following day while standing in the kitchen 
he again fell and had to be helped back to bed. There was no loss 
of consciousness during these falling attacks. During the week 
Defore admission he had incontinence of urine on two occasions. 
There was no disturbance in the rectal function. The weakness 
of the extremities has remained stationary since the onset of his 
illness. For the past six months he has suffered from a dull head- 
ache in the occipital region. At times these headaches were 
associated with vertigo, but he never vomited. The patient states 
that for the past six months he has noticed that his memory was 
failing. 

Summary of the History. — There has been double vision for 
17 days. Weakness of the left arm and both legs for 10 days. 
Swelling of the right eyelid and pain in the right nostril for seven 
days. Unsteadiness in gait for seven days. Incontinence of urine 
on two occasions one week ago. Headache and vertigo, with failing 
memory for the past six months. 

Physical Examination. — The patient was a well-developed and 
well-nourished middle-aged man. His pupils were equal, regular, 
and reacted promptly to light, and when he attempted to converge. 
The left eyeball was completely immobile due to an external ophthal- 
moplegia. There was moderate weakness of the right external 
rectus. A nystagmoid movement in the lateral plane was present 
in the right eyeball. There was some weakness in the other muscles 
of the right eye, but these were not especially tested out. Ptosis 
was present on both sides, the left more marked than the right. The 
fundi were normal. Some facial immobility was present on both 
sides. The other cranial nerves were intact. 

The teeth were in good condition, the tongue was clean and 
moist. The tonsils were not enlarged but the pharynx was con- 
gested. There was no rigidity of the neck, the thyroid was not 
enlarged and no abnormal pulsations were felt in the neck. The 
chest showed poor expansion, and the lungs were emphysematous. 
The heart sounds were poor quality, and a soft systolic murmur 
was heard at the apex. The abdomen was negative. 

The motor power of the upper extremities was poor, more so 
on the left side. The patient was scarcely able to raise his arms to 



EPIDEMIC ENCEPHALITIS 37 

a right angle and was unable to maintain them in that position for 
more than an instant. The weakness was most marked in the axial 
groups of muscles and became less marked in the muscles of the arm, 
forearm, and hand; the grips however, were quite poor. Similar 
distribution of the muscle weakness was found to a less marked 
degree in the muscles of the lower extremities. When the patient 
attempted to stand his knees would give way suddenly and if he 
was not supported the patient would collapse. No atrophy or 
fibrillary twitchings were observed. The muscles of the trunk 
were also weak so that the patient was unable to raise himself from 
a recumbent to a sitting position without assistance. 

The deep reflexes at the wrist, elbow, shoulder, ankle, and knee, 
were present and equally active on both sides. They were perhaps 
slightly more active than normal. The abdominal, cremasteric and 
plantar reflexes were present and normally active on both sides. 
There were no pathological reflexes. There was no ataxia or 
adiadochokinesis. Sensory examination for touch, pain, vibration, 
muscle and joint sensibility was normal. There was no astereog- 
nosis. Mentally the patient was alert, well oriented, and cooperated 
in the examination. In spite of the patient's statement, no defect in 
memory could be established. 

Laboratory Findings. — The blood and spinal fluid Wassermann 
was negative. The spinal fluid was under slightly increased pressure, 
showed a little increase in the globulin content and no cells. The 
blood pressure was 120 systolic and 80 diastolic. The blood 
chemistry was reported by Dr. Bookman to be normal. The urine 
examined on several occasions showed a trace of albumin and rarely 
a hyaline cast. X-ray examination of the chest did not reveal any 
enlargement of thymus ; it showed a tuberculous infiltration of 
both apices. Electrical examination of various muscles by Dr. 
Harris was reported negative on two different occasions. Ex- 
amination of the labyrinth by Dr. Friesner showed caloric stimula- 
tion of the left ear to be positive in 25 seconds ; in the right in 4c 
seconds. During the caloric stimulation there was little, if any, 
change in the eye movements. There was however a marked in- 
crease in the ptosis of the left lid ; a phenomenon which is anatom- 
ically difficult to explain. There was no spontaneous nystagmus, 
vertigo, or pass-pointing. The functional tests indicated that there 
was a lesion in the nuclei. 

Clinical Course. — On a number of occasions the patient stated 
that there was a marked increase in his muscle weakness at night. 
On January 6, at 12.30 A.M. he was examined by Dr. Krauss and 
me and we found that his weakness was not greater than during the 
day time. Complete external ophthalmoplegia was noted in the 
right eye on the 26th of December. January 10 slight motion in the 
eyeballs and improvement in the patient's general condition was 
noted ; the next day the ptosis seemed to be less marked. On 
January 17 there was tendency toward the Babinski response. On 
January 18 for the first time since entering the hospital he had 
incontinence of urine. January 24 slight atrophy in the interossei 



38 MORRIS GROSSMAN 

became apparent ; it was thought to be due to disuse. On January 
25 the patient complained of paresthesia on the right side of his 
face, and also that he was having difficulty in breathing. His speech 
was found to be nasal in character. January 27 the patient com- 
plained of difficulty in opening his mouth. His speech was decidedly 
nasal, but the soft palate seemed to move freely. January 31 the 
patient began to have difficulty in swallowing, but did not regurgi- 
tate fluids through his nose. The ptosis was slightly more marked 
on the left side. External ophthalmoplegia was complete on both 
sides. The palate moved poorly. The power in both masseter 
muscles was diminished. The muscle power in the shoulder girdles 
was somewhat improved. On February 6 the bulbar symptoms 
became aggravated, the respiration became labored, and the patient 
died the next day of typical medullary paralysis. 

Autopsy of the brain was permitted. The following is a pre- 
liminary report by Dr. J. H. Globus on the pathological specimen 
obtained. Grossly the brain showed marked congestion. This was 
most pronounced in the medulla, giving the appearance of marked 
cyanosis. No hemorrhages or thickening of the leptomeninges were 
noted. 

Microscopic findings in a limited number of sections proved 
to be of particular interest on account of the unusual features 
that were found. These lesions showed characteristics of a sub- 
acute inflammatory process, with acute infiltrative changes and 
multiple hemorrhagic foci superimposed upon them. The sub- 
acute character was recognized by thickening of the walls of the 
blood vessels, and through the proliferation of the adventitial 
elements, as well as by multiple areas of gliosis. 

The acute changes were expressed by lymphocytic infiltration 
of the adventitial spaces, numerous small perivascular hemorrhages, 
and early degenerative changes in the parenchyma. These changes 
were most pronounced in the mesencephalon, though they were also 
noted in the pons and medulla. 

The acute changes are strongly suggestive of the lesions found 
in acute epidemic encephalitis, with the difference that other lesions, 
subacute in nature, were added to the pathologic picture. 

The results of a more detailed study of the material will be 
incorporated in a separate report at a later date. 

Case 3. B. B. 18. Stenographer. Born in the United States. 
Entered the hospital March 9, 1921. Her chief complaints were 
increasing weakness in the upper and lower extremities ; occasional 
attacks of diplopia, and difficulty in chewing her food and in 
swallowing solids. Duration : one week. 

Family History. — Negative. 

Past History. — Measles, diphtheria, and scarlet fever during 
childhood. Menstrual history is normal. No serious illness after 
puberty. 

Present Illness. — This began four weeks ago with dimness of 
vision, associated with vertigo, and gradually increasing weakness in 
the upper and lower extremities. She has occasionally suffered 



EPIDEMIC ENCEPHALITIS 39 

from fleeting attacks of diplopia since the onset of her illness. The 
vertigo lasted one week and then disappeared. The weakness in her 
extremities has gradually been getting more pronounced so that 
now the slightest exertion induces marked fatigue. For the past 
week the patient notices that when chewing solid food her jaws 
become tired very easily and that she has difficulty in swallowing 
solid food. Liquids are taken with less difficulty and are not 
regurgitated through the nose. These has been no insomnia, 
somnolence, or irregular involuntary movements in any of the 
muscles, with the exception of a tic of the orbicularis oris on the 
right side. Her bladder and rectal functions remain undisturbed. 
Physical Examination. — The patient is moderately well nour- 
ished. There is bilateral ptosis of the eyelids, slightly more marked 
on the left side. The right pupil is a little larger than the left, but 
both react promptly and completely to light and convergence. The 
outward excursion of the eyeballs is somewhat limited in both lateral 
planes on account of a slight weakness of both external recti 
muscles. There is a recurrent clonic tic of the right orbicularis 
oris. The facial folds are flattened on both sides, the left being 
more pronounced than the right. The motor and sensory portions 
of the fifth nerve are intact. The tongue protrudes centrally, and 
does not show any atrophy or fibrillary tremors. The uvula is 
central and does not move on producing sounds, but moves normally 
in response to palatial stimulation. The hearing and fundi are 
normal. The patient is unable to raise the arms to a right angle 
when lifting them up at the sides, but when holding her arms 
forwards she is able to do so and can hold them up for a few 
minutes. The other muscles of the shoulder girdle also show some 
weakness, but the deltoids, especially the left, seem to be most 
affected. The biceps and the triceps also show some weakness but 
to a less degree than the muscles of the shoulder girdles. Only 
slight weakness is present in the muscles of the forearm ; the grips 
are fairly good. There is atrophy in the posterior portion of both 
deltoids, and the supraspinal, but no fibrillary tremors are present. 
No typical myasthenic reaction of the muscles could be demon- 
strated, but the muscles showed a rapid fatiguability and could not 
be maintained long in any one position. The muscles of the trunk 
are also affected and the patient is unable to raise herself from a re- 
cumbent to a sitting position without aid. The pelvic muscles and 
those of the lower extremities showed less marked weakness 
than the muscles of the upper extremities, but the distribution was 
similar, the axial groups being more profoundly affected than the 
distal groups. The deep reflexes at the shoulder, elbow, wrist, knee 
and ankle are all present and hyperactive on both sides. There 
was no tendency to exhaustabilitv on either side, after repeated 
stimulation of the tendons. The abdominal reflexes are present and 
equally active on both sides. No definite Babinski could be elicited. 
The Oppenheim and Gordon responses are not obtained. There is 
no ankle clonus. The muscle tonus is normal. There is no ataxia 
or tremor of either the upper or lower extremities. Occasionally a 



4o MORRIS GROSSMAN 

slight choreiform twitch is present. No sensory disturbances are 
present. 

Laboratory Findings. — The blood and spinal fluid Wassermann 
was negative. Ten c.c. of clear spinal fluid was removed; the 
pressure was not increased, and no cells were found. The globulin 
content was normal. Electrical reactions did not show any ab- 
normality. No myasthenic reaction was present. The urine was 
normal. 

Clinical Course. — On March 14, wasting of the trapezi was 
noted. The ptosis seems to be more marked in the evening. March 
16, the patient complained of marked dysphagia and could not 
swallow solid food at all ; even milk was swallowed with great 
difficulty. There was no regurgitation of fluids through the nose. 
The weakness of the shoulder girdle muscles is less marked. The 
orbicular tic occurs more frequently and choreiform movements 
are slightly more definite. Very slight tremor of both hands is 
present. The patient is emotional, but the intelligence is normal. 
March 18 the weakness of the shoulder girdle muscles has increased 
and the patient complains of great subjective fatigue. The tongue 
deviates to the right. The weakness in the external recti remains 
about the same. With these slight variations the patient's condition 
is about the same as when she entered the hospital. 

Comment. — These cases presented clinical pictures simulating 
myasthenia gravis so closely that the positive diagnosis was not 
definitely made for some time. The apparently acute onset of the 
illness, the age of the patients in case one and two at the time of 
onset; the lack of variations in the degree of the muscular weak- 
ness ; the absence of true myasthenic fatigue phenomenon ; the 
absence of the myasthenic electrical reaction ; the persistent hyper- 
active inexhaustible deep reflexes ; and the complete persistent 
external ophthalmoplegia pointed against the diagnosis of myas- 
thenia gravis. The persistent eye muscle palsies, the unequal pupils 
in case two, the increase in the deep reflexes in all three patients, 
the bladder disturbance in case two, the tendency to the Babinski 
phenomenon in the first two patients, the atrophy in the muscles in 
all three patients, the acute course of the disease in case two, 
and lack of remissions formed the basis for the diagnosis of acute 
epidemic encephalitis. The pathological findings in case two con- 
firmed the diagnosis in one case in a group of three patients who 
presented remarkably similar clinical pictures. 



^octets iproceeotnoe 



NEW YORK NEUROLOGICAL SOCIETY AND THE SEC- 
TION OF NEUROLOGY OF THE ACADEMY OF 
MEDICINE 

Joint Meeting of November i, 192 i 

Dr. Foster Kennedy, President of the Society, and Dr. S. P. 
Goodhart, Chairman of the Section, presided jointly 

FOURTH VENTRICLE TUMOR WITH SURGICAL 
INTERVENTION 

Dr. I. S. Wechsler presented a patient of twenty-nine, seen 
May 25, 192 1, complaining that in November, 1920, she had dizziness 
and spells of momentary darkness before her eyes, lasting a few 
seconds. Occasionally she did fall, though to no particular side. 
To overcome the vertigo she had to hold her head in a rigid position. 
The spells of dizziness used to disappear for a few weeks, then set 
in again. Frequently she would lose her vision suddenly for periods 
lasting from two to five seconds. No headache, no vomiting, no tin- 
nitus. She had gained thirty pounds and her menses had become 
irregular, prolonged and profuse. 

Examination showed a somewhat acromegalic face, gait, co- 
ordination, deep and superficial reflexes, sensory function, and cranial 
nerves normal except for inequality of pupils, LR, and bilateral 
choked disk of five diopters. The diagnosis of tumor of the fourth 
ventricle was made, tumor because of the choked disk, and fourth 
ventricle because of remissions, of the need of holding the head rigid 
to overcome the vertigo, which was interpreted as a modified Bruns 
symptom, and because of the absence of other localizing signs. 

On admission to the Mt. Sinai Hospital the blood Wassermann 
and urine were negative and the blood chemistry was normal. There 
was eosinophilia amounting to seven per cent. The X-ray showed a 
normal sella and no signs of pressure. Dr. Elsberg performed a 
suboccipital craniotomy and found a tumor filling the fourth ven- 
tricle. It was adherent to the floor and sides and to the calamus 
scriptorius. An attempt to remove a piece of the tumor resulted in 
bleeding, which, owing to the dangerous location, necessitated a 
rapid retreat. The tumor appeared to be either a glioma or epen- 
dymoma. 

For a short time after the operation she remained unchanged, but 
later developed some dysarthria, a little staggering, vomiting and 
slight optic atrophy. She was discharged from the hospital within a 

41 



42 NEW YORK NEUROLOGICAL SOCIETY 

few weeks. At no time did she have nystagmus, pyramidal tract 
signs, cranial nerve palsies or sensory disturbances. The patient is 
still living, five months after the operation. She has improved 
somewhat. 

The interesting points considered were : ( i ) The diagnosis of 
fourth ventricle tumor during life and its verification at operation, 
based on a modified Bruns symptom and choked disk. (2) The 
absence of all signs of fourth ventricle tumor, such as pressure 
symptoms on the medulla, pons, cerebellum and cranial nerves. Par- 
ticularly noteworthy were the absence of vomiting, headache, rigidity 
of the neck, polyuria or glycosuria, and vagal symptoms. 

• Discussion 

Dr. M. Neustaedter asked what was the pulse ratio? 

Dr. S. P. Goodhart said these cases are very rare and both the 
patient and the doctor were to be. congratulated. 

Dr. B. Onuf asked if a titubation were present. 

Dr. Wechsler said that the pulse was always within average 
limits and so was the respiration ; during the operation and following 
the operation, for a few days, of course, that does not apply. The 
nature of the tumor could not be determined, and an attempt to re- 
move it, if it had been carried on, would have resulted in the bleeding 
to death of the patient. From the appearance of it, it was between 
a glioma and an ependymoma. It appeared to be a soft tumor. 

A PRINCIPLE, HITHERTO UNDESCRIBED, OF THE 

PHYSIOLOGY OF MOVEMENT AND POSTURE. 

THE PRIMITIVE SPINAL INTEGRATION 

OF MOVEMENT IN VERTEBRATES 

Dr. Walter M. Kraus said that at the present time movements 
are described in such terms as extension, abduction, internal rotation, 
etc. In other words, activity controlled by a neuromuscular mech- 
anism is being described in terms of the muscular part of that mech- 
anism alone. Every description of movement leaves out the neuro- 
logical element of that movement. The description of its control by 
the spinal cord and its peripheral nerves is left out. When a com- 
plicated movement guided by integrations of the nervous system at 
levels higher than the spinal cord is described, a consideration of the 
final neuromuscular mechanism is omitted. In other words, the 
foundation of the control of movement by the spinal cord is left out 
when such words as flexion, extension, abduction, etc., are used. It 
would seem wise to add some terms to those describing muscular 
movements which would give a notion of the embryology of these 
muscles as well as their innervation. This, as will be pointed out, 
can be done very simply. 

The nervous system is unquestionably built up of a series of 
physiological levels, of which the higher or more recent ones, phylo- 
genetically speaking, carry out functions which are different from 



NEW YORK NEUROLOGICAL SOCIETY 43 

the lower ones. It is his opinion that some conception of the inte- 
grating action of the lowest levels must be obtained in order to 
interpret the higher levels. It must be known, in other words, how 
the spinal cord integrates movements, in order to understand how 
such higher integrations as the cerebellar, act, and ultimately to 
understand why it has become necessary for these higher integrations 
to appear at all. 

In order to examine this question of the existence of integration 
of movement of the spinal cord, it becomes necessary to consider in 
detail the general plan of peripheral nerves, the general plan of the 
innervation of muscles by them, and the embryological grouping of 
muscles. It was his intention throughout to present only the simplest 
facts in connection with these structures. 

A typical thoracic spinal nerve, having nothing to do with the 
limbs, shows a number of divisions after it has been made up of the 
posterior and anterior spinal roots. The common trunk so formed 
divides into an anterior and a posterior division. The anterior divi- 
sion divides further into a lateral and an anterior branch. Further- 
more, the lateral branch divides into two, a dorsal and a ventral. As 
far as the axial musculature is concerned, the portions of it developed 
from the ventro-lateral portions of the embryo are supplied by the 
anterior division and its branches, while the postero-musculature is 
supplied by the posterior branches. Thus a very simple scheme re- 
sults from a physiological viewpoint, in the notion that general move- 
ments of extension are guided by the posterior division, while flexion 
and lateral movements are guided by the anterior division. When 
tin's is applied to the limb plexuses, two theories appear. Before 
stating them, it is necessary to emphasize that the limb plexuses do 
not include any part of the posterior division. One theory assumes 
that the plexuses are made up of the entire anterior division, the 
other that they are made up entirely of the lateral branch of this 
division. For the purposes of this discussion it does not seem at the 
moment very important to try to reach a decision as to which of these 
theories is correct. That theory which states that the plexus is 
made up solely of the lateral branch is chosen and the details of the 
problem are discussed in these terms. 

The lateral branch divides into a dorsal and ventral branch. The 
primitive extremities of the embryo are flattened buds having a dorsal 
and ventral surface. The premuscle mass on the dorsal side gives 
rise to muscles, the majority of which, in the adult, have an extensor 
function. The premuscle mass on the ventral side of the bud corre- 
spondingly gives rise to muscles, the majority of which have a ventral 
function. The crux of the whole situation lies in the fact that when 
considering the simplest function of a muscle it is found that certain 
of them have a function opposite to that which would be expected 
from a knowledge of the side of the limb bud (ventral or dorsal) 
from which they develop; for example, the iliopsoas group develops 
from the dorsal muscle mass of the lower limb bud. However, they 
have a ventral function — that is, flexion. 

To return now to the question of innervation, it is found that the 



44 NEW YORK NEUROLOGICAL SOCIETY 

embryology of the muscles is beautifully emphasized by the innerva- 
tion of these muscles. It is well known that the nerves of the brachial 
and lumbo-sacral plexuses divide into two very definite groups ; one 
of which is posterior or dorsal and the other anterior or ventral. In 
the arm the ventral branches of the brachial plexuses innervate the 
subclavius and pectoral muscles as well as all the muscles supplied by 
the musculo-cutaneous and ulnar nerve. What is found when de- 
tailed table of muscles is made, based upon (i) whether they have 
been derived from the dorsal or ventral aspects of the limb bud. (2) 
whether they are supplied by dorsal or ventral branches of the limb 
plexuses, is that those muscles which develop from the dorsal layers 
of the bud are supplied by the dorsal branches of the limb plexus. 
The analogy to the condition in the axial musculature is obvious. 

From all this one arrives at some possibility of schematization. 
It is found that the nerves derived from the brachial plexus are 
divisible topographically into two very large groups, one ventral and 
the other dorsal, which, in turn, supply muscle groups which are 
ventral and dorsal in origin (Paterson) . On going further and adding, 
on the chart, the function of these muscles, one is struck with the 
fact that, as in the case of the iliopsoas mentioned before, a muscle 
which would be expected to have an extensor action has in reality a 
flexor action. In other words, were one to group the muscles acti- 
vated in any given movement merely on the basis of their activitv as 
muscles, and leave out of consideration the origin of their embryology 
and activating nerves, one would be leaving out entirely the division 
of these nerves and of their end organs, the muscles, into a large 
ventral and dorsal group. 

To illustrate how this information may be used for the purpose 
of discovering just how the spinal cord may integrate movement, let 
us take the process of stepping. If the extreme forward movements 
of the leg be represented, it will be seen at once that the forward 
movement is carried out by the iliopsoas, quadriceps and tibialis 
anticus muscles. Though this forward movement of the leg as a 
whole is spoken of as flexion, it is quite obvious that it is of dorsal 
origin, since all the muscles which carry it out are of dorsal origin. 
On the other hand, the carrying backward of the leg is brought about 
by the hamstrings, gastrocnemius and soleus group, and the tibialis 
posticus, all muscles having a ventral innervation and being of ventral 
embryological origin. Consequently the movement of extension of 
the leg as a whole at the hip is, in reality, ventral in origin. To go 
further and take the associated movements of the arms and legs, 
when the left arm is forward and flexed, the left leg is extended at 
the hip, flexed at the knee and extended at the ankle. It is generally 
stated that the arm and leg on the same side are acting oppositely, 
in that the arm is flexed while the leg is extended, and the arm is. for 
example, forward while the leg is backward. If this be interpreted 
in terms of the neuromuscular mechanism controlling it, rather than 
in terms indicating the geometrical relations, such as flexion, exten- 
sion, etc., it is found that the arm and leg on the same side are both 
directed, in this particular example, by ventrally innervated muscles, 



NEW YORK NEUROLOGICAL SOCIETY 45 

so that the notion that the arm and leg go in opposite directions on 
the same side must be reversed when the neuromuscular mechanism 
is considered as the basis of movement. 

It is proposed that to the words now used to indicate the activity 
of a muscle, such as flexion, abduction, extension, etc., two words be 
added, namely, ventrad and dorsad, which would serve to indicate 
three things: 

i. The embryological origin of the muscle. 

2. The nerve supply of the muscle (ventral or dorsal branches). 

3. The primitive direction in which the limb was carried by that 

muscle. 

By adding these terms we describe movement in terms of the neuro- 
muscular mechanism, instead of leaving out the activity of the nerv- 
ous system entirely. 

Furthermore, the primitive integration of movements of the spinal 
cord is seen to be one which throws into activity the muscles which 
develop together and are innervated together. This very simple 
movement of a group of such muscles must be brought about by a 
correlation mechanism within the spinal cord, and forms the founda- 
tion of movement. So simple a movement as could be brought about 
by the simple activation of large groups of what were primitively 
ventral or dorsal muscles was obviously insufficient for the needs of 
animals. Further and different integrations of movement became 
necessary, and so not only the spinal cord, but the more recently 
developed portions of the nervous system, came into existence, in 
order to make possible these new and more complicated patterns of 
associated movement. An example of one of these within the spinal 
cord itself is the flexion reflex, " flexion of the three great joints." 
This term gives the impression of a certain homogeneousness of ac- 
tion which, when interpreted in terms of the neuromuscular mech- 
anism, is found to be entirely absent, in that flexion of the hip is a 
dorsad movement carried out by the iliopsoas group, flexion of the 
knee is a ventrad movement carried out. in this instance, by the ham- 
strings, and flexion of the ankle is a dorsad movement carried out 
by the tibialis anticus. 

Note: The paper as originally presented was but a bare outline 
of the matter which should have been presented. An abstract of 
such a paper must of necessity leave a great many points of the 
greatest importance untouched and must leave undiscussed many of 
the points presented. 

Discussion 

Dr. S. E. Jelliffe said that he wished he knew enough to discuss 
intelligently the paper that Dr. Kraus had given. His modesty, he 
said, forbade him to enter into a criticism, because he felt certain 
that Dr. Kraus has emphasized a method, a new method of analysis 
of motion. Whereas for himself the embryological evidence always 
lags behind the phylogenetic argument, he should like very much to 
have Dr. Kraus, in his further expositions of the situation, link up 



46 NEW YORK NEUROLOGICAL SOCIETY 

the phylogeny of these movements and show wherein they conform 
to the present embryological schemes. Then he thought that a cer- 
tain number of the difficulties that Dr. Kraus himself had suggested 
would perhaps be clarified. 

He said the paper had provided a stimulus whereby further obser- 
vation of muscular activities will take on an entirely new aspect. 

Dr. Kraus said, in reply to Dr. Jelliffe's remarks, he thought that 
the phylogeny of the matter is the only ultimate way to decide it. 

The reason for bringing these little animals down was to empha- 
size that point. He did not think, however, that it was necessary to 
give the " why " of these things to emphasize the facts. The facts 
remain. What he tried to emphasize throughout was that what he 
was dealing with were facts, not theories. We must, I believe, speak 
in terms of the neuromuscular mechanism and not of muscular mech- 
anism only. 

Dr. Stookey's emphasis of the many functions of a single muscle 
is extremely pertinent. We must take a primary function first and 
then try to explain, if we can (and in many instances we can), why 
a muscle assumes a secondary function. Take, for example, the 
activity of the flexors of the wrist. There the prime action is 
flexion ; but they have also assumed an action of adduction or abduc- 
tion. We must, as you see, examine these movements carefully be- 
fore reaching conclusions. 

Now, as to the use of the abductor of the little finger, or let us 
take the abductor of the thumb — that certainly is abduction ; it is 
from the middle line, the axis of the extremity. But as I am speak- 
ing of terminology, I should like to emphasize that when we speak 
of it as abduction, we think of it in the same way as we think of 
abduction of the arm, though the innervation and embryologv indi- 
cate that one is dorsad, while the other is ventrad. If we use the 
terms ventrad and dorsad, we know how different is the innervation 
in these two cases. I do insist (and I will make this the only point 
I would like to insist entirely upon) that we must use the neuro- 
muscular mechanism as a basis for the interpretation of movement 
and not the muscular only. If we are going to interpret the activity 
of higher levels, we must interpret that through the nervous system. 
We must not pass from the action of the cortex to flexion, for ex- 
ample, without knowing in the least how the spinal cord has come 
into that integrating action. 

SOME THERAPEUTIC EXPERIENCES OF MYASTHENIA 

GRAVIS 

Dr. Charles L. Dana stated that the prognosis of this disease 
as generally given was very bad ; according to Oppenheim, 26 out of 
38 cases died ; Dr. Hun found that most cases die in from one to 
three years; Dr. M. Allen Starr found that about 45 per cent, of the 
cases collected by him died within six months. Dr. Dana stated that 
his experience had been quite different, and he felt he ought to record 
it. He had had under observation 14 cases in the last 20 years; he 
had not been able to follow up the histories of all of them, and some 



NEW YORK NEUROLOGICAL SOCIETY 47 

had died from natural causes ; but, in general, he could say that none 
of them had died of the disease while under his observation, and he 
had had them under observation for from one to seventeen years. 

Table Showing Duration of Disease While Under Observation 

i year, 5; 2 years, 1; 4 years, 1; 5 years, 1; 6 years, 1; 7 years, 1; 12 
years, 1 ; 13 years, 1 ; 17 years, 1. 

Table of Results 

Recovered 4 

Practically well 3 

Improved 4 

Not improved 1 

Died of cancer 1 

Not followed up 1 

14 

Dr. Dana thought that the better prognosis of the cases was due 
in part at least to the treatment which he had employed. This con- 
sisted of massive doses of strychnine combined with rest and elimi- 
nation. The doses reached in some cases one third grain given 
hypodermically two or three times a day. 

The speaker also referred to the frequency of prodromal attacks ; 
in 50 per cent, of his cases the serious attacks were preceded by short 
attacks lasting only a few weeks and characterized by some ocular 
symptoms and bulbar weakness. In some cases these prodromal 
attacks were not followed by any other attack for many years ; in one 
case as long as seventeen years elapsed. Dr. Dana called attention 
to this fact and thought it quite probable that mild abortive attacks 
of myasthenia gravis characterized by diplopia and slight exhaustion 
of the bulbar centers were not infrequent. In some cases the pro- 
dromal seizure was simply an ocular one, and one of the causes of 
casual ocular palsies of permanent type was undoubtedly myasthenia 
gravis. This fact was not recognized in the systematic works on 
ophthalmology. Dr. Dana referred to myotonia as an occasional 
complicating symptom of myasthenia. He thought the disease toxic 
and endogenous and one that affected both motor neuron and muscle. 
He had seen no result of note in endocrine therapy. 

Discussion 

Dr. Bernard Sachs said that Dr. Dana's contribution to this 
subject is of great interest, and he was willing to endorse his rational 
therapy. There is nothing surprising in the fact that he has em- 
ployed strychnine. In the cases that he had had at the hospital 
during the past ten years the uniform treatment, particularly for the 
bulbar symptoms, has been the use of strychnine, but of course they 
have not employed it in any such doses as Dr. Dana now recom- 
mends, and he should be very glad, when the opportunity presents 
itself, to put that high dosage to a further trial. His experience has 
been an extremely fortunate one. He confessed that of all the cases 
in which he had made the diagnosis of myasthenia gravis pseudo- 
paralytica only very few recovered or remained alive long enough for 
him to record a temporary recovery. 



48 NEW YORK NEUROLOGICAL SOCIETY 

He wondered, though, if Dr. Dana hasn't experienced very much 
the same thing that he had experienced in the course of these years : 
First of all, that the disease that some of us call myasthenia gravis 
pseudoparalytica includes a number of rather discordant types of 
disease, and he thought, particularly in view of the experience that 
we have had during the past few years with various forms of enceph- 
alitis, not only the encephalitis lethargica, he wondered whether, in 
view of that experience, we should not all be inclined to think that 
some of the cases that we labeled as myasthenia gravis were really 
some form of encephalitis. There are no doubt other forms of in- 
fectious encephalitis besides encephalitis lethargica, and personally 
he was inclined to think that some of these cases that have been 
covered may have been cases of that type and not cases of myasthenia 
gravis. 

He was referring to this fact more particularly because of an 
experience which they have been undergoing for the last two or three 
years at the hospital. His associates and himself have been very 
deeply interested in all forms of bulbar palsies and we have seen a 
rather curious number of extremely complicated and difficult bulbar 
cases. Some of them they were inclined to regard as myasthenia 
gravis, and in other cases again they really were not able to label the 
cases in that way. One or two of the cases recovered; others died, 
and the entire subject still remains more or less of a mystery to him, 
except that he has no doubt that there are cases that are due to severe 
toxic products circulating in the body. It would be only a short 
jump from that to the supposition that some of the cases were due to 
infections of all sorts in the body, and he believes that a further 
study would probably prove to us that many of these cases are really 
distinct forms of encephalitis. The actual proof of that, as you can 
easily recognize, would be a rather difficult one to secure. 

He would, however, like to know whether Dr. Dana himself 
would be rather inclined, in view of our recent experiences, to accept 
that view in regard to the interpretation of some of the cases that we 
labeled as myasthenia gravis. If he were simply to state a general 
impression as to the number of cases he would be willing to call 
myasthenia gravis, he would say that he had not seen more than six 
or ten of them in so many years. So that the subject is one, he 
thought, that is well worth considering in every way. 

He would like to have Dr. Dana state whether the symptoms 
actually cleared up rather promptly on the administration of the 
large doses of strychnine; for instance, whether the ptosis disappeared 
and whether the tongue symptoms cleared up, whether there was a 
prompt recovery or not, on the exhibition of the strychnia. It seemed 
to him to be a rational method of procedure and he should be only 
too glad to adopt Dr. Dana's suggestion and benefit by his experience. 

Dr. L. P. Clark said that a number of years ago at the National 
Hospital for Paralytics and Epileptics, Sir William Gowers was very 
keen on the use of strychnine in his myasthenia gravis cases. He 
was particularly impressed with the enormous advantage that he 
gained from such administration. Later he had the opportunity of 
noting cases in the service of Dr. Starr at Vanderbilt Clinic. He 



NEW YORK NEUROLOGICAL SOCIETY 49 

saw advantages in the foreign cases, but did not recall advantages 
obtained on this side with either small or large doses. He continued 
to use strychnine for a period of two or three years, beginning with 
small doses and running up to a fourth of a grain. 

He said he would like to ask Dr. Dana, who has had a very con- 
siderable personal experience, how he explains the rational thera- 
peutics of the strychnine, if this is some form of glandular dis- 
turbance (which now seems more than likely) ; how does the strych- 
nine operate against an organic conductivity of the systemic values? 

He had been very much surprised to note the enormous suggesti- 
bility that these cases have and the neurotic attitude they take toward 
the disease. Several months ago he was asked to see a case, not 
because of the myasthenia gravis, but because there was possibly a 
neurosis superadded. The diagnosis seemed quite correct and every- 
thing had been done for the patient that was possible. He suggested 
that he get a change of environment by taking a rest in the country. 
He was very much surprised the other day when this man's wife 
came to see him and reported that he was walking two miles, was 
engaging in all sorts of activities, and everything but his speech 
(which was predominantly bulbar in type) was enormously improved. 
Simple advices had evidently impressed the patient and had much 
more to do with his betterment than any special therapy that had 
been undertaken. 

Why would it not be a good idea to try the glands on other cases, 
if. as the doctors say, the disease is the fault of some gland? He 
was particularly impressed after he saw this patient that he was 
going through a rather definite, almost a psychotic delirium of his 
disease, and he was surprised to see the type of mental reactions he 
was taking through this organic detail. There are certainly enough 
cases on record for us to work toward eliminating that particular 
issue and also take up some of those that Dr. Sachs has suggested, of 
other types of infections. 

He should like to end by asking Dr. Dana upon what rationale is 
the strychnine acting. Is it against the functioning of a certain 
unknown gland? 

Dr. Jelliffe said that while listening to Dr. Dana's paper his 
thoughts had run along the lines that Dr. Sachs had so well empha- 
sized. That whereas one can predicate type of reaction focused 
about what is termed myasthenia gravis, shading off from such a 
picture a great number of semi, demi types are observable, some of 
which undoubtedly belong in with the groups which Dr. Sachs has 
emphasized ; also others that heretofore have been called periodic 
palsies, and a whole group of phenomena related to irregular muscu- 
lar reactions due to acute or chronic conditions chiefly in the medul- 
lary nuclei. It seemed to him that that is a useful way of looking 
at the whole situation. Of course, if, with a certain trend of mind, 
one is apt to lump all these things together and speak of a disease 
sui generis, then he thought Dr. Dana's attitude of mind quite justi- 
fied. However, if one is inclined to see so-called pure types and 
divergent types and a whole group of situations which clinically may 



5o NEW YORK NEUROLOGICAL SOCIETY 

be grouped about a very definite syndromy, it seemed to him the 
results which had been reported were quite comprehensible. 

Dr. Dana has spoken of the endocrine situation. It seemed to 
him that Dr. Dana sketched too broad and glaring a type of gen- 
eralization. He felt disposed to think that if the particular group 
of glandular involvements had a certain specific action, either on one 
or the other branches of the vegetative nervous system, then one 
could commence to predicate an endocrine disorder. That is to say, 
one might say, " Here is a disturbance in a muscular mechanism 
which is doubly innervated." The sympathetic arc of the vegetative 
mechanism, it seemed to him, is the one that is most primarily in- 
volved in the pure types of myasthenia gravis. If that be so, there 
is a very good rationale why strychnine should be of value in that 
type, because it is, of all of the plant alkaloids, the most powerful 
stimulant to the sympathetic branch of the vegetative nervous system. 
That is also a reason why calcium is therapeutically of value, and 
why sometimes the myasthenia gravis cases appear very closely re- 
lated to parathyroid disturbance. 

Dr. B. Rosenbluth said the subject of myasthenia gravis inter- 
ested him greatly. In studying the literature, he had come across a 
similar disease occurring in Switzerland and also in Japan, which 
offered all the symptomatology of myasthenia gravis. This disease 
occurs in the most crowded quarters and among the poorest class of 
people who are undernourished. For example, in Japan it is found 
among the laborers in the rice fields, and it is found among people 
usually who are terribly underfed and undernourished. He had had 
only four cases, and instead of using any medication, he had put the 
patient to bed and kept on feeding him by means of the duodenal 
tube. Dr. Larkin cultured one case and was unable to discover any- 
thing definite; and he had a similar experience and negative results 
in another case. The two cases of myasthenia gravis which recov- 
ered might have been an erratic type of this form of disease. It is 
very possible that with more refined bacteriological technique one 
might recover and be able to correlate this disease with its occurrence 
in the different parts of the earth. That being the case, we can see 
the reason that any form of treatment that is kept up long enough, 
with stimulation and nourishment, will bring the patient over the bad 
part of it for two or three years. These cases take a very long time. 

Dr. Dana asked if this disease kept on recurring every year. 

Dr. Rosenbluth said it recurs every two, three or four years. 

Dr. Charles E. Atwood said he wished to call attention merely 
to one fact in relation to this disease. Of course, we have all seen 
a number of cases and we realize that they are subject to remissions, 
and that the disease renews itself frequently by fatigue. Possibly 
the explanation of the renewal of the symptoms is from the sub- 
oxidation which takes place in fatigue. He has a case of myasthenia 
now that has lasted since 1907. The case has done the best with 
hygienic symptomatic treatment and small doses of strychnine. The 
myasthenic reaction is one of the most reliable tests, perhaps, in dif- 
ferentiating myasthenia gravis from other diseases. 

Dr. Foster Kennedy said his experience in this matter has been 



NEW YORK NEUROLOGICAL SOCIETY 51 

that there is rather a difference of prognosis in the subjects who are 
young; i.e., in the subjects who are under forty and in the subjects 
who are over forty, it being decidedly worse in those who are in their 
twenties. The disease, as he has seen it, has run a very much shorter 
course in the young than in the middle aged or aged. 

He mentioned to Dr. Dana that he had been fortunate enough to 
see a series of autopsies on myasthenia gravis, with the extraordinary 
chance that in five of them an enormously enlarged thymus existed. 
This thymus was not so very great as regards glandular bulk, but it 
was great as regards glandular expansion. The thymus existed as 
an object perhaps two thirds the size of my hand, stretching down 
over the pericardium — a very extraordinary phenomenon, one which 
certainly can not be without significance in the disease, though its 
exact correlation with the symptoms I am not able to state. 

Dr. Charles L. Dana said he was much obliged to the gentle- 
men who have joined with so much interest in a discussion of this 
subject. It certainly is a very interesting one and one which seems 
to him to deserve further and closer scrutiny. With regard to the 
point that Dr. Sachs made. Dr. Dana had written this — he didn't 
read it : " Myasthenia Gravis is a disease which runs peculiarly true 
to type," etc. Therefore, he thinks that Dr. Sachs's suggestion that 
we ought to scrutinize these cases with especial care is a very wise 
one. He thinks that one case he had in mind was perhaps not true 
myasthenia gravis, though he thought it was at the time. You must 
not think that you have to give massive doses of strychnine always 
or all the time. He finds sometimes that a fifteenth of a grain is 
enough, and sometimes even a little less ; but it seems to him that 
the most permanent and satisfactory results were those in which these 
larger doses were given for a considerable time. 

With regard to the frequency of the time or the effect of the dis- 
ease, the symptoms do not clear up right away. You will have to 
use the injections for perhaps three or four weeks before they begin 
to show, and it seems to Dr. Dana, from his experience, that there is 
nothing psychical in the patients. The patients he had seen were 
treated seriously, of course ; when he saw them, they were put to 
bed a large part of the time; they were kept very still; they were 
given these very large doses and they knew they were being actually 
treated. There wasn't any suggestion about it. nor were there any 
psychic elements in the case. 

He doesn't quite understand Dr. Jelliffe's remarks. It seems to 
him the disease is a poison of the somatic rather than of the sympa- 
thetic part of the system. 

1 )k. Jelliffk replied that the somatic muscles have a double 
innervation, sensori-motor and vegetative, and that involvement of the 
sympathetic was a better hypothesis, he believed. 

Dr. Dana said that he thought it was sensori-motor innervation 
that is affected. 

In regard to the point made by Dr. Kennedy, I can only say that 
one of my cases, one of the very best ones, a boy of nineteen, has 
now been well for six years; but all the other cases were in the 
thirties or forties — perhaps more of them beyond forty than under it. 



Current literature 



II. SENSORI-MOTOR NEUROLOGY 

4. MIDBRAIN; CEREBELLUM. 

Pol, D. J. Hulshoff. Experimental Cerebellar-atactic Phenomena 

in Extra-cerebellar Affections. [Koninkl. Akad. v. Wetenschap- 

pen te Amsterdam, 1919, XXI, 1095 (3 figs.).] 

Pol has shown that our equilibrium organ is not exclusively located 
in the vestibular organ, but has its arborizations throughout the whole 
body, the vestibular apparatus forming but a part of it. The equilibrium 
tracts, which run centripetally as the tracts of Flechsig and of Gowers, 
possess exactly the same function as the fibers of the vestibular appa- 
ratus; sensory cerebellar ataxia, then, should occur when these two 
tracts are damaged in their course through the cerebellum. Pol there- 
fore attempted to interrupt experimentally these tracts before they reach 
the restiform body, and also to injure more or less the vestibular nerve 
before it arrives within the dura. The operation was done in two stages 
on cats and dogs. In the first the spino-cerebellar and the funicular 
posterior tracts were transsected; when the operation was done above 
C x all the cats died, so it was done between C 2 and C 3 . The pyramidal 
tract was slightly damaged by the operation. In about a fortnight the 
ataxy had passed off and the second operation was then performed. The 
labyrinth and the vestibular nerve were destroyed; five cases were suc- 
cessful. Pol concludes that by transsecting the tracts of Goll, Burdach, 
Flechsig and Gowers and the fibers of the vestibular organ it is possible 
to provoke cerebellar ataxia ; and that these experimental results confirm 
his previous clinical findings that sensory cerebellar ataxia occurs 
through interruption in the cerebellum of these four afferent tracts. 
[Leonard J. Kidd, London, England.] 

Pol, D. J. Hulshoff. Cerebellar Functions in Relation with their 
Localization. [Psychiatrische en Neurologische Bladen, 1915, No. 
3 (4 figs.).] 

From his experiments on dogs and from a critical review of the lit- 
erature Pol concludes that the mammalian cerebellum performs many 
functions. It exercises a static, sthenic and taxic influence on the mus- 
cles; loss of this function gives Luciani's secondary ataxia; this function 
appears to be uniformly spread over the whole cerebellar surface (Lu- 
ciani, van Rijnberk, Hulshoff Pol). The cerebellum also influences the 
degree of muscular movement; loss of this function gives dysmetria of 
movements; this function is localized in Bolk's centers, especially, ac- 
cording to Pol, in Bolk's lobulus paramedianus; lesion of this lobe gives 

52 



SENSORIMOTOR NEUROLOGY 53 

in dogs the "parade step" (goose step). Thirdly, the cerebellum di- 
rectly governs the coordination of muscular movements (Hulshoff Pol) ; 
loss of this function gives primary incoordination; this function is local- 
ized in Bolk's sublobulus C of the lobulus medianus posterior, and this 
center subserves coordination of movements in the hind limbs. Finally, 
the cerebellum has a direct influence on the condition of the equilibrium 
of the body; this function is localized in the fibers of the nervus octavus 
which end in the cerebellar roof nuclei (Winkler, Evvald). According 
to Pol, the ataxic signs of Luciani are produced by lesion of Bolk's 
lobulus medianus posterior, lobulus paramedianus, and crus 2 of the 
lobulus ansiformis. In addition, a lesion of crus 2 of the ansiform lobule 
gives dysmetria of movements, shown in dogs by the " cock's stride." 
[Leonard J. Kidd, London, England.] 

Stenvers, H. W. The Diagnosis of Pontile Angle Tumors. [Neder- 
landsch Tijdschr. voor Geneeskunde, 1920, LXIV, November 6, 1871.J 
The diagnosis of pontile angle tumors may be very difficult; in five 
out of six cases a wrong diagnosis was made by neurologists and by 
otologists. Stenvers narrates a case which was described in 1916 as 
one of unilateral reflex anesthesia of the trigeminus nerve, and in 1919 
as disseminated sclerosis; the latter diagnosis was based largely on the 
absence of appearance of illness, the ability to do his daily work, absence 
of attacks of loss of consciousness and of vomiting, slowness of pulse, 
headache and of vertigo. Stenvers shows that all these symptoms may 
be absent in pontile angle tumors; in his experience the pulse frequency 
in these cases .has been either normal or greatly raised. The patient 
mentioned above was a man of 26, examined by Stenvers in March, 
1919. In 191 5 he had tingling and attacks of neuralgic pain in his left 
trigeminus nerve, followed by gradual right deafness and vertigo. He 
had remission of symptoms from time to time and this fact helped to- 
suggest disseminated sclerosis. In March, 1919, he had limitation of 
visual fields, some degree of bilateral optic neuritis, large reacting pu- 
pils, both corneal reflexes diminished, especially the right. Right deaf- 
ness with left trigeminus paresthesia and neuralgia, left facial paresis 
and to a lesser extent right also, nystagmus to both sides, ataxic gait 
with deviation now to right and then at times to left. When standing 
with eyes shut he falls backwards, to left especially; asynergia is seen 
in failure of knee flexion as he falls. Echinococcus reaction in blood 
+2. Negative von Pirquet and also Wassermann in blood. A bitem- 
poral x ray photo showed a secondarily greatly dilated sella. The 
vestibular reactions were normal. Stenvers cites cases of right pontile 
angle tumors with left trigeminus neuralgia. An x ray photo in his 
case showed erosion of the medial part of the right petrous bone, the 
left being normal. This objective fact proved the existence of a right 
pontile angle tumor. Operation removed a tumor of considerable size; 
death two days later, with bulbar symptoms. This case illustrates the 



54 CURRENT LITERATURE 

vital importance of an x ray photo of the petrous bones. In all the 
cases of pontile angle tumors, verified by necropsy, seen by Stenvers, 
erosion of the petrous bone has been found. And in all the ten cases 
clinically examined by him an x ray plate of the petrous bones has been 
diagnostically successful. He relates also a case of a peripheral lesion 
which simulated a pontile angle tumor: On necropsy a carcinoma of the 
gall bladder was found; a metastatic extracranial growth gave severe 
trigeminal neuralgia, etc., and had proliferated through the middle cra- 
nial fossa (figured). There was no trace of any pontile angle tumor. 
The moral of Stenvers' paper is that in the diagnosis of these pontile 
angle tumors an x ray photo of both petrous bones is essential, for by 
ordinary clinical tests these tumors are often not correctly diagnosed. 
[Leonard J. Kidd, London, England.] 

Stenvers, H. W. Clinical Study of Cerebellar Function and the 
Diagnosis of Cerebello-pontile Angle Tumors. [Drukkerij 
" Davo," Deventer, June, 1920, pp. 150 (10 figs.).] 
In this Utrecht University thesis Stenvers gives an excellent clinical 
study of the cerebellum and of ponto-cerebellar angle tumors, and dis- 
cusses the nature of the function of the human cerebellum. Chapter 1 
contains a review of the chief opinions held on cerebellar functions. In 
chapter 2 cases of pontile angle tumors are detailed. Chapter 3 contains 
clinical observations on some cerebellar symptoms. And chapter 4 
gives Stenvers' views, based on his own clinical observations. His con- 
clusions are as follows: 

1. The diagnosis of pontile angle tumors is often clinically very 
difficult. 

2. In all cases of these tumors seen by him a rontgenographic study 
of the petrous bones has proved of great diagnostic value. 

3. For a good differential diagnosis the posterior cranial fossa needs 
photos of the petrous bones by Stenvers' method; the method of Hen- 
schen-Quix is insufficient for this purpose (an illustrative case is given). 

4. In pontile angle tumors there may be most variable and change- 
able conditions of the facialis innervation. 

5. The presence of intact vestibular reactions does not exclude the 
possibility of a pontile angle tumor. 

6. Auditory neuritis (stauung-neuritis) does not cause great deaf- 
ness. Its presence on one or both sides, without any peripheral aural 
affection, indicates a local lesion of the cochlear root or nuclei. 

7. The majority of the tumors hitherto described as ascusticus tumors 
do not deserve that name ; they are better called pontile angle tumors. 

8. Pontile angle tumors grow towards the occipital foramen, the 
place of least resistance. 

9. Nystagmus is not a cerebellar sign. 

10. Diadococinesia (quick pronation and supination) is intimately 
related to a good functioning of the homolateral cerebellar hemisphere, 
while the vermis has no share in that function. 



SENSORIMOTOR NEUROLOGY 55 

ii. The pointing errors of Barany are of great value in the diagnosis 
of cerebellar diseases, but their use needs caution. 

12. In the disturbances of gait in cerebellar affections there is no 
definite rule as to the direction in which the patient falls. 

13. In cerebellar lesions involving the middle peduncle the patient 
mostly falls to the side of the lesion. 

14. Cerebellar speech disturbances can occur in cases of unilateral 
cerebellar hemisphere of the side on which the arm is mostly used, e.g., 
lesion of right cerebellar hemisphere in right-handed persons and vice 
versa. (This subject has been greatly neglected by most writers.) 

15. The pointing test of Barany depends on a reflex mechanism which 
is brought about by both cerebrum and cerebellum. 

16. The pointing errors produced by Stenvers' prism tests are analo- 
gous to Barany's vesetibular stimulation methods. (Illustrative cases 
are here detailed. This method needs, however, a degree of visual 
acuteness which is often absent in cases of pontile angle tumors.) 

17. The gait disturbances described by Bruns in some cases of frontal 
lobe lesions are not truly comparable to those of cerebellar affections. 
(Stenvers describes a personal case.) 

18. The cerebellum is not a coordination center, but is to be regarded 
as a reflex organ that unconsciously regulates and influences our volun- 
tary movements that are coordinated elsewhere in the central nervous 
system. [Leonard J. Kidd. London, England.] 

Atkinson, E. D., and Drought, C. W. Two Cases of Early Paralysis 

A 1. 1 tans. [Lancet, July 10, 1920.] 

Without careful analysis these two cases are reported as of paralysis 
agitans, in soldiers, both under the age of 30 years. Whether due to 
midbrain hemorrhages from shock, epidemic encephalis or syphilitic en- 
cephalitis of midbrain localization is not analyzed. 

Porru, C. Arsenic in Paralysis Agitans. [Policlinico, September 6, 
1920.] 

The old arsenical therapy of paralysis agitans has reappeared. Large 
doses of sodium cacodylate are being used. Slight if any benefit was 
the rule and it was transient in all but one case. 

Schippers, J. C. Tremors in Children. [Nederland. Tijdschr. voor 

Geneeskunde, 1920, LXIV, September 11, 983.] 

According to Peritz, tremors occur relatively seldom in children. 
Pelnar distinguishes tremor from athetotic and choreiform movements 
and defines it as consisting of small involuntary movements oscillating 
round a position of equilibrium; it is fairly regular, and is localized in 
a joint or a group of cooperating joints; it causes no fatigue and does 
not interfere with movements. As to its nature, he thinks that in the 
static innervation of skeletal muscles we have to do with an oscillating 



56 CURRENT LITERATURE 

and undulating tetanus; the oscillations have a frequency of fifty per 
second, the undulations one of eight to thirteen waves; only the latter 
can be registered by a sensitive apparatus; they are really the true 
tremors; in static innervation they have the oscillating intensity of a 
continuous tetanus. Kollarits regards tremor as a sequel of a disturb- 
ance of coordination of agonistic and antagonistic muscles; since even 
during rest a certain activity of muscle takes place, there is thus no 
particular difference between trembling during rest and in movement; 
the cause of the tremor must be looked for in the cerebral cortex. Pel- 
nar gives the chief kinds of tremor thus: Physiological tremor in healthy 
persons, emotional tremor, adynamic tremor, tremor from cold or trauma, 
tremor from poisons, as alcohol, nicotine, ergotine, mercury, the thyroid 
gland, etc., uremic and eclamptic tremor, neurotic tremor, tremor in 
Basedow's and in Parkinson's disease, in organic nervous diseases, he- 
reditary and familial tremor, and tremor from commotio. 

Schippers here records five cases of various kinds of tremor in chil- 
dren : (i) hereditary familial tremor in a boy of eight; fine, quick tremor 
in arms; genitalia large for his age, but no sexual precocity; the family 
history showed the true nature of the tremor; (2) two cases of acute 
cerebral tremor in infants under two years of age; this kind of tremor 
is sometimes of unilateral distribution, sometimes limited to arms or 
legs; there may be lively reflexes, spastic signs, pareses, ataxia; once 
facial paresis and nystagmus ; the tremor usually follows an acute infec- 
tion, as pneumonia, measles or intestinal catarrh; it lasts for from two 
to twelve weeks and is usually of good prognosis; (4) a sporadic case 
of cerebrospinal meningitis of a two months' infant, with tremor, and 
(5) an infant of twelve months in whom tremor of arms on emotion was 
present; lumbar puncture showed a meningitis. Necropsy showed a 
ventricular meningitis and great hydrocephalus. Tremor as an early 
sign of meningitis is seldom seen, but Hutinel regards prodromal tremor 
as a diagnostic sign of meningitis in children. Schippers concludes from 
his observations that tremors in children, when nonsymptomatic, are of 
the greatest importance; their presence should lead us to a careful search 
for other signs of central nervous system affection, and eventually to 
lumbar puncture. [Leonard J. Kidd, London, England.] 

Winkler, C. Anatomical Changes in the Brain of a Cerebellec- 
tomized Dog. [Nederland. Tijdschr. voor Geneeskunde, 1920, LXIV, 
September 4, 958.] 

Winkler describes to the Amsterdam Neurological Society the ana- 
tomical changes in the brain of a dog cerebellectomized five months 
previously by Dusser de Barenne. The knife had passed between the 
flocculus and the brain stem without damaging the tuberculum acusticum 
or the nucleus ventralis VIII. Certain complications of this successful 
operation were produced, viz., an extensive hydrorhachis of C 4 and 
slight degeneration in both pyramidal fields; certain motor disturbances 



SENSORIMOTOR NEUROLOGY 57 

had been present during life, probably dependent on these. In the spinal 
cord much of the marginal zone of the lateral column had gone. There 
was some loss of fibers in the dorsal spinocerebellar tract, and no cells 
were found in Clarke's columns. There was much cell loss in the pars 
intermedia medulla, possibly dependent on the disappearance of the ven- 
tral spinocerebellar tract. In the bulb there is no loss of the large cells 
of the nuclei of von Monakow, Goll or Burdach, nor in the lemniscus 
medialis. But a large number of the medium sized cells have fallen out, 
and this goes with a poverty of the internal pons fibers. Winkler thinks 
that the medium sized cells of the dorsal column nuclei (except von 
Monakow's nucleus) are connected with the cerebellum by internal pons 
fibers via the restiform body. The resti form body contained no normal 
fibers. The large cells of the dorsal column nuclei are a little smaller 
than normally occurs. Roughly speaking all the cells of the lateral col- 
umns and the group of uppermost olivary nuclei are gone, and no exter- 
nal arcuate fibers are seen; for both lateral column nuclei this holds 
good for the ventral part; there a great part of the aberrant lateral 
column bundle is absent and the nucleus here reaches the surface; tra- 
becula are found there without cells. But in the more dorsal parts of 
the lateral column nucleus fine large cells are seen. Accordingly, Wink- 
ler thinks the lateral column nucleus may be divided into a distoventral 
part which sends its fibers to the cerebellum through external pontile 
bundles, and a dorsoproximal part that does not. At the distal end of 
the group of the lower olivary nuclei the nuclei are lost on both sides 
and there is but little of the gelatinous material in which they lie. In 
the lateral bend, which the left lateral column band makes, one finds 
about its middle and in the more proximal parts a group of cells crowded 
together, while both parts of this nucleus contains preserved cells (a 
small part of the right of the cerebellum has been left behind at the 
operation). The adhering roots of the nervus octavus showed no 
changes. On both sides the radiations of the cochlear and the vestibular 
nerves and the descending root of the nervus octavus are normal. Thus, 
Winkler cannot admit that octavus root fibers end directly in the cere- 
bellum or its intrinsic nuclei. Both tubercle acustica are normal. The 
ventrodistal end of the ventral nucleus of the nervus octavus contains 
normal cells; the cell masses between the fibers of origin of the cochlear 
nerve are normal ; on both sides the corpus trapezoides is powerful and 
the trapezoid nuclei and those of the uppermost olivary nucleus group 
are normal ; so also are the lateral fillet and its ventral and dorsal nuclei 
and the posterior corpus quadrigeminum. But the dorsoproximal part 
of the ventral octavus nucleus is importantly altered, especially on the 
left; its medium sized cells have gone and in the proximal end of the 
nucleus there is a sharply divided line between its normal and its affected 
parts. Winkler concludes that a bundle passes from the dorsoproximal 
part of the ventral VIII nucleus along the pedunculus flocculi to the 



58 CURRENT LITERATURE 

cerebellum. Notwithstanding the splendid radiation formed by the ves- 
tibular roots in the nucleus triangularis VIII, this nucleus is very small, 
owing to the falling out of large cells, the right and the left nuclei being 
equally diminished. At the same time the longitudinal fibers in the 
corpus justirestiforme (I. A. K. of von Monakow) are diminished, with 
the exception of descending vestibular roots therefrom. The great loss 
of large cells which lie in groups in the nucleus triangularis shows that 
the medial and lateral perforating fibers in the juxtarestiforme body 
arises therefrom, and that thus the nucleus triangularis VII forms pow- 
erful connections with the cerebellar nuclei. The large cells of Deiters' 
nucleus and also the vestibulospinal and the vestibulomesencephalic 
tracts are normal. The pons shows greater changes than the bulb; its 
breadth is not one third of normal; the left peduncle contains no unin- 
jured fibers; on the right, a very small part of the peduncle remains 
connected with the wrinkled piece of the lobulus ausatus (left behind 
by operation). The ventral nuclei of the pons (Winkler uses for this 
complicated gray matter the nomenclature of Besta, Masuda and Brou- 
wer) : (a) the medial nucleus; on both sides there is loss of all its cells 
and a rich secondary glia proliferation; (b) the intra- and peri-pedun- 
cular wicker work; although the trabeculae are left there are no cells 
therein; (c) dorsal, dorsolateral nuclei; on both sides all cells have dis- 
appeared; (d) lateral nucleus; all cells gone on both sides; (e) the left 
ventral nucleus has no cells in its distal end but soon we find normal 
cells in it (coming from the opposite cerebellar remnant). Both its 
small superficial and large, more deeply situated cells are diminished in 
number but are to be called normal in so far as they are preserved; 
these cells are found running laterally of the uninjured pes pedunculi 
through the pons and are seen even in the most proximal sections. The 
right ventral nucleus has lost almost all its cells, but in its middle part a 
very small group of intact cells is seen. To sum up : There is complete 
cell loss in all the nuclei of the ventral pons formation, with the excep- 
tion of the ventral nucleus; the nucleus on the side opposite to the cere- 
bellar remnant contains a very large number of normal cells, while that 
on the homolateral side has but few normal cells. Evidently this cell 
preservation is connected with the presence of the remnant of the lobu- 
lus ansatus left by the operation. But the very severe and extensive 
cell loss in this ventral pons formation justifies the opinion that the cells 
of this gray mass send their fibers exclusively to the cerebellum. The 
ventral nucleus sends its axons to the contralateral lobulus ansatus, but 
only a few axons go to the latter from the homolateral ventral nucleus. 
Winkler has compared his preparations with carmine preparations made 
from a hemicerebellectomized rabbit, and is convinced that unilateral 
destruction of the cerebellum does not lend itself to a judgment on the 
question; on the contrary nothing is so apt to confuse the judgment 
over the ventral pons nuclei as a study of unilateral or partial cerebellar 



SENSORIMOTOR NEUROLOGY 59 

lesions, even when comparison with the normal is possible. For, as 
appeared in his own dog, the crossed ventral nucleus especially had lost 
many cells, but in all the other nuclei the cell loss was bilateral. Thus, 
he accepts the old opinion that the cells in the ventral pons formation 
belong to the cerebellum. Finally, in the brain stalk the brachia con- 
junctiva, the uncinate bundle and the ventral spinocerebellar tract are 
gone. No intact fibers were found. The superior cerebellar peduncular 
decussation is reduced to a field filled up by glia proliferation. The 
field of the red nucleus is very small; the fibers around and in it are 
gone. The gray wicker work, in which the large polygonal cells of the 
red nucleus are enclosed is almost entirely missing, but these large cells 
are preserved. Winkler says that the most important part of this re- 
search is that all the cells of the ventral pons formation have disap- 
peared except a small part of the ventral nucleus on the side opposite to 
the intact remnant of the lobulus ansatus, paraflocculus and flocculus. 
Thus, these nuclei, just as the lower olivary nuclei, are connected ana- 
tomically with the cerebellum. Winkler was not sufficiently certain as 
to the changes in the small celled part of the red nucleus to enable him 
to form a judgment. [Leonard J. Kidd, London, England.] 

5. BRAIN; MENINGES. 

Harbitz, F. Is Tuberculous Meningitis Curable? [Norsk Magazin 

for Laegevidenskaben, July, 1920. J. A. M. A.] 

Harbitz cites evidence from the literature that tuberculous meningitis 
can pass into a phase of fibrous transformation which results in the com- 
plete cure of the active disease. Rossle has reported a case of chronic 
tuberculous meningitis in a woman of 37 with final fatal coma after 
seventeen months, and Harbitz here describes a similar chronic case 
with a five and possibly eight months' course in a man of 38 with ne- 
cropsy findings showing mild tuberculous meningitis just entering a 
phase of anatomic healing. Another feature of the case was the spread- 
ing of the infectious process along the blood vessels into the brain and 
spinal cord, thus presenting the picture of diffuse tuberculous encepha- 
litis and myelitis. In 60 per cent, of cases of tuberculous meningitis, 
the patients are infants, and in them it is invariably fatal. The instances 
of a chronic course and recovery are nearly all in adults, the resisting 
powers or increased immunity aiding in the struggle against the infec- 
tion. Epidemic cerebrospinal meningitis often entails hydrocephalus 
and changes in the brain, with mental disturbance. But tuberculous 
meningitis seems to escape this tendency. If the patient recovers he is 
not left with defects. Lumbar puncture and tuberculin treatment may 
contribute to the favorable outcome. In conclusion Harbitz cites a case 
from Overland's practice in which a girl of about 7 had long presented 
symptoms of tuberculous meningitis, but finally recovered and in time 
married and has borne two children. 



60 CURRENT LITERATURE 

Hollis, Austin W., and Pardee, Irving H. Tuberculous Meningitis 
and Antimeningococcic Serum. [Arch. Int. Med., July 15, 1920.] 

Thirty-eight undoubted cases of cured tuberculous meningitis are 
reported in the literature and fifteen in which the diagnosis was doubt- 
ful. Except for these cases, hospital statistics show that the treatment 
has been ineffectual. Intraspinal injections of antimeningococcic serum 
combined with frequent spinal drainage, was used by the authors in two 
cases of tuberculous meningitis, and in two other possible cases, recovery 
following. Three cases in the last four years were treated by serum at 
St. Luke's Hospital with ultimate death. Of the successfully treated 
patients, three were young men in excellent physical condition with a 
localized meningeal form of tuberculosis. In the unsuccessful cases, 
two were those of men over 45, one alcoholic, one arteriosclerotic, the 
third was of poor physique. The injection has two distinct actions, it 
adds to the spinal fluid certain antibodies which it is unable to develop 
for itself, and it introduces within the dura a foreign protein, horse 
serum. The unilateral effect of the latter on the meninges produces a 
cellular response and a hyperemia about the site of any localized tubercle. 

Araoz, Alfan G-. Pseudotuberculous Meningitis. [Arch. Latin-Amer. 
de Pediatria, May-June, 1920. J. A. M. A.] 

Araoz remarks that most of the cases that have been published of 
recovery from tuberculous meningitis were in reality of other origin. 
He makes an invariable practice of seeking for tubercle bacilli in the 
lumbar puncture fluid; many assert that if sought repeatedly and pa- 
tiently for hours, they can be found in 90 to 100 per cent, of all cases 
of tuberculous meningitis. With negative findings he inoculates animals 
and begins mercurial treatment at once, as he is convinced that the 
meningitis with inherited syphilis, in infants or older children, and in 
the acute phases of the third stage of syphilis presents a clinical picture 
and lymphocytosis which deceptively simulate true tuberculous menin- 
gitis. Even with a history of syphilis, the meningitis may be a super- 
posed tuberculous infection. The onset of syphilitic meningitis is usually 
more abrupt and stormy than with the tuberculous type; there is fever 
and there may be convulsions and a semicomatose state. The menin- 
gitis may be secondary to a vicinity reaction to otitis or secondary to 
mumps. The fluid cell count is predominantly polynuclear or mixed, 
and the high fever and intensity of other symptoms resemble more those 
with epidemic meningitis. Examination of the salivary glands may give 
the clue. One case is on record in which mumps meningitis merged 
into the tuberculous form. Meningeal reactions to alimentary intoxi- 
cation in infants may prove misleading, but the lymphocytes are few in 
number and the glucose content is high; in one case it reached 1. 1 per 
thousand. Leukocytosis is common, and the rapid improvement under 
restriction to water confirms the alimentary intoxication. The urea 



SENSORIMOTOR NEUROLOGY 61 

content of the spinal fluid runs up high. Retention of urea in spinal 
fluid and blood from kidney disease may simulate tuberculous meningitis 
until laboratory tests have been made. Morquio has reported a case in 
which by exclusion tuberculous meningitis seemed the only diagnosis in 
spite of the absence of tubercle bacilli, but the child recovered after all. 

Lannois and Sargnon. The Acute Otologic Meningitides. [Rev. de 
Laryngol., d'Otol., et Rhinol., 1920, July 15, p. 385.] 
The writers treated a very large number of cases of acute otogenic 
meningitis at a military hospital during the War. They attribute their 
good results to early interference. The first thing is to suppress the 
focus of infection; thus, one curettes the whole of the mastoid and 
attacks every possible purulent focus under the dura or around the sinus. 
They treat these acute cases by daily lumbar puncture at the onset, and 
then every other day until all grave symptoms have disappeared; if any 
alarming symptoms reappear the lumbar punctures are repeated. In 
some cases they have added intraspinal injections of electrargol or of 
electraurol, but they are not sure of their value, for some of their acute 
cases recovered without them. In addition, whenever it was possible, 
they used large hot baths daily, at 39 to 40 C, for half an hour. After 
recovery from the acute meningitis, complications may occur, such as 
attacks of vertigo and epilepsy. [Leonard J. Kidd, London, England.] 

Christiansen, V. Chronic Serous Meningitis. [Hospitalstidende Co- 
penhagen, November 5-December 10, 1919.] 

This author states that serous meningitis as an uncomplicated patho- 
logical lesion is not known for the posterior cranial fossa. It usually 
accompanied a tumor of the cerebellum or cerebellopontine angle. In 
twenty cases of tumor in this region which he had observed in six years 
serous meningitis had been constant. It also occurs with tumors else- 
where in the skull. 

Schenk, E. Circumscribed Serous Meningitis. [Deut. med. Woch., 
February 19, 1920.] 

An old shrapnel wound of the cervical cord in a man of 31 was 
operated by laminectomy chiefly to relieve pain and avoid morphinism. 
Removal of the vertebral arches of C III-C VI, was done under local 
anesthesia. The dura was inflamed and without pulsation. Incision 
with scissors caused 30 c.c. of cerebrospinal fluid to escape under high 
pressure, after which the cord began to pulsate. Adhesions and mem- 
branes, which were extremely tough, were divided and removed. The 
patient began to improve at once. The following day the pain had 
almost disappeared. Later the sensory and motor phenomena regressed 
perceptibly. The injury to motion, however, proved to be irreparable. 



62 CURRENT LITERATURE 

6. BRAIN. 

Constantin. Spontaneous Escape of Cerebrospinal Fluid through 
the Nose. [Rev. med. de l'Est., July 15, 1920.] 

This condition has been described by St. Clair Thomson in England ; 
Freudenthal and Jelliffe (Chordoma) in the United States; Babinski, 
Sicard, Claisse, and Levy in France ; Wollenberg, Nothnagel and 
Adolph Meyer in Germany, and Noccioli in Italy, as well as others. In 
only a few cases have autopsies been performed. In four a cerebral 
tumor was found; in other cases the escape of cerebrospinal fluid was 
due to a fracture of the base of the skull or injury to the cribriform 
plate. In Constantin's case the phenomenon occurred suddenly, with- 
out any trauma or sign of a cerebral tumor. The rhinorrhea was ob- 
served to occur drop by drop from the right nostril exclusively at the 
rate of five drops a minute, or 860 c.cm. in the twenty-four hours. 
When the patient was in the horizontal position the discharge ceased, 
and the fluid was swallowed without interfering with the patient's sleep. 
Examination of the nasal fossae and skiagrams of the skull showed 
nothing to explain the condition. 

Parnell, R. J. G-., and Dudley, S. F. Severe Cerebral Toxemia after 
Intravenous Novarsenobillon. [Lancet, January 24, 1920.] 

A case of secondary syphilis which was being treated with this ar- 
senic compound is here reported. The first dose was 0.45 gm. producing 
no reaction and the second, 0.9 gm. given four days later produced no 
reaction until fifty-six hours after injection into the vein. The patient 
began to vomit and during the next three days he had a series of seven 
epileptiform convulsions with unconsciousness, biting of the tongue, 
incontinence of urine and feces, together with a macular eruption on the 
skin, marked cyanosis and failing pulse. Adrenalin injections, calomel 
in hourly doses, and lumbar puncture failed to relieve the symptoms, so 
oxygen inhalations were given to combat the evident anoxemia and caf- 
fein 0.2 gm. with urotropin 1.5 gm. in 15 c.c. of sterile distilled water 
was given to relieve the maniacal state, probably through the great 
diuresis resulting. Five hours after the injection was begun and the 
oxygen inhalations were started the patient had become entirely rational 
and thereafter made an uneventful recovery, though he suffered from 
a partial amnesia for fourteen days. 

Lantuejoul. Spontaneous Coagulation of Spinal Fluid. [Rev. 
Neur., April, 1920.] 

Lantuejoul reviews the literature on spontaneous and massive coagu- 
lation of the lumbar spinal fluid. Of the 38 cases he has compiled, there 
was meningitis in 5 and paraplegia in 28. Spinal fluid drawn by punc- 
ture at different levels was normal at the higher levels. Of the total 
38 persons, 14 have died, and only 5 can be considered cured. Massive 



SENSORIMOTOR NEUROLOGY 63 

coagulation of spinal puncture fluid must therefore be considered a sign 
indicating a grave prognosis. Xanthochomia was pronounced in all but 
one case. The coagulation is due to an often enormous increase in the 
albumin content and to the presence of an abnormal constituent, namely, 
fibrin. Necropsy in 11 of the cases showed that the lower portion of the 
subarachnoid space was shut off either by the meninges growing together 
or by compression. The repeated lumbar punctures gave great relief. 
Froin was the first to call attention to this massive coagulation of the 
spinal fluid. [J. A. M. A.] 

Barbe, A. Permeability of the Choroid Plexus. [Rev. Neur.. April, 

1920.] 

Cadaver experiments on the permeability of the choroid plexus 
showed that human blood serum transfused readily. Certain variations 
in different diseased conditions are noted. Thus permeability is in- 
creased in paresis and diminished in some epileptics. 

Tanaka, Fumio. Absence of Lobus Olfactorius and Sclerosis of 
Corm: Ammonis. [Am. Arch. Neur. and Psych., August, 1920.] 

The very rare condition of a brain without olfactory tracts is de- 
scribed with minute account of the macroscopic and histologic findings, 
together with history of patient with epileptic dementia from whom the 
brain was taken on necropsy. There were bilateral absence of the bul- 
bus and tractus olfactorius, rudimentary development of the trigonum 
olfactorium in both hemispheres, absence [left] and partial development 
[right] of the sulcus olfactorius nondevelopment of the gyrus olfac- 
torius medialis and lateralis as well as of the gyrus tuberi olfactori in 
both sides, absence of the stria olfactoria and some atrophy of the gyrus 
hippocampi in both hemispheres. The rhinencephalon showed no nota- 
ble alateration. The absence of the gyrus olfactorius medialis and lat- 
eralis and the gyrus olfactorii and the stria olfactoria would not be of 
importance in regard to the question of the olfactory center. It was 
not possible to obtain any information regarding the patient's sense of 
smell during life. The origin of the defect of the olfactory lobe is be- 
lieved to develop when some compression acts on the head fold of the 
embryo. Tanaka believes that the defect in his case had its origin in a 
defect in embryonal tissue. As explanation of microscopic changes 
found in the cornu ammonis, in addition to the anomaly of the olfactory 
lobe, arteriosclerosis may be taken into consideration, but the patient 
did not have arteriosclerosis and the basal arteries showed only slight 
hardening. There is no evidence of any kind of intoxication which 
might cause these marked changes. The cornu ammonis therefore 
appears to be affected by the defect of the olfactory center, and the 
author concludes that the cornu ammonis must be regarded as the termi- 
nal olfactory center. Sclerosis of the cornu ammonis has been noted 
before in some cases of epilepsy, thus making the final conclusion on this 
point uncertain. [Stragnell.] 



64 CURRENT LITERATURE 

de Vries, E. Gliosis and Sclerosis. [Nederland. Tijdschr. voor Ge- 
neeskunde, 1920, May 29, p. 2000.] 

de Vries has shown to the Amsterdam Neurological Society a case 
of glioma, occurring in an old dipsomaniac woman, that ran the course 
of a dural hematoma. The aspect of the tumor varies in relation to its 
site. In the right occipital lobe, in which it probably originated, there 
is cortical gliosis, the convolutions having preserved their shape, but 
being broader and whiter than normal and of irregular surface. Micro- 
scopically the tumor here consists of small round glia cells with definite 
body protoplasm but mostly without processes. The ganglion cells here 
lie between them or else are already atrophied. In places where the 
changes are not yet so marked, glioma cells often lie in the areas where 
the original glia cells are situated (satellite cells next to the ganglion 
cells, along the vascular sheaths). Here one has the impression that 
the preexistent glia cells have themselves become tumor cells as soon as 
the process came near them, and that thus we have here an infective 
and not an infiltrating growth. In these sclerotic convolutions there is 
no glia reaction with formation of astrocytes or ameboid cells. In other 
places the picture is quite different : the tumor appears there as an astro- 
cyte glioma or a sacro glioma, while in one place there are giant cells 
in the tumor tissue, with a ganglin like aspect. Where these parts of 
the tumor lie immediately beneath the cortex they provoke a glia reac- 
tion such as we see everywhere from irritation, viz., increase and ame- 
boid enlargment of the cells, de Vries here showed preparations from 
a case of apparent brain tumor ; there was here a diffuse increase of the 
glia. A similar condition is found in some idiots where the brain is 
indurated from the diffuse glial increase, especially in the cortex. Also 
in epilepsy this form of gliosis occurs. In other cases the greatest 
change is found in the medullary substance. A case was shown in 
which extensive fiber degenerations occurred in the medullary substance, 
probably due to a glial proliferation, as is never found in ordinary sec- 
ondary degeneration; the U-shaped association fibers escaped. In the 
cortex there was induration and there were small warts on its surface; 
the cerebellum also was wrinkled. Finally, de Vries showed two cases 
of lobar sclerosis, one in an adult, the other in earlier life; here the pre- 
dominant feature is the destruction of ganglion cells, the glial prolifera- 
tion being slight and probably secondary. [Leonard J. Kidd, London, 
England.] 

Rietz, T. Narcosis Tremor and its Treatment. [Surg. Gyn. and 

Obst., April, 1920, Vol. XXX, No. 4.] 

The author calls attention to a tremor during general anesthesia 
hitherto not described and shows a method to obviate this inconvenience. 

Norcosis trembling resembles very much a series of frequent rhyth- 
mic muscular contractions. These are sometimes so violent that they 



SENSORIMOTOR NEUROLOGY 65 

are almost mistaken for clonic cramp. The trembling attacks chiefly 
the lower extremities, but sometimes the trunk is also involved. The 
spasm remind one most of the findings in cases of intense tremor, of 
epileptic attacks, or spasms from other cortical irritation. 1 Usually the 
trembling comes on suddenly, without warning, and as a rule immediately 
reaches its full intensity; then, after a longer or shorter period it dis- 
appears as suddenly as it appeared. There are no single detached spasms 
later, such as one sees in eclampsia or epilepsy. The phenomenon always 
appears as a series of rapid spasms at regular intervals. Sometimes the 
trembling appears only as slight, rapid, spasmodic jerks lasting for a 
fraction of a minute. In some cases the trembling continues as long as 
five minutes and in some cases even longer. 

Thirty-three cases in all have been observed during the years 1912 
to 1919. With two exceptions only, the patients were men. 

Because of the character and course of the attacks in our series, we 
feel justified in comparing them with the rhythmic contractions which 
occur in a number Qf other conditions and which are considered to de- 
pend on an abnormal irritation, influencing in some manner the motory 
courses. This is generally believed to occur in the cortex of the brain, 
but as to the nature of this disturbance, we know very little. 

The narcosis tremor must be due to an irritation which is produced 
in some manner by the narcotic which is conducted to the brain through 
the circulation of blood. 

Neither the hospital records nor the objective examination of the 
patient has afforded any exact means of determining the factors which 
may possibly be considered as favoring the appearance of the above 
described spasms. We are forced to assume that the abnormal irritation 
which produces these motory symptoms has some connection with a 
special sensitiveness in these patients. 

On the hypothesis that narcosis tremor is the result of an abnormal 
irritation of the brain produced by the anesthetic which is conducted 
thither by the blood, Rietz has endeavorder to overcome this phenome- 
non. To eliminate, at least for a moment, the influence of the irritated 
motor centers, during an operation on a boy of 16, he pressed, for a few 
seconds, on the neck in the fossa carotica. The result was evident at 
once ; the narcosis tremor disappeared as by magic. It appeared again, 
however, when the pressure was removed. Renewed experiments had 
precisely the same effect. When pressure was again applied for a some- 
what longer period (about one quarter minute), the spasms ceased 
definitely. 

Although on some occasions the monoeuvre had doubtful results or 
none at all, continued observations still showed that the measure was of 
value. As regards the effect of pressure, the cases may be divided into 
three groups. The first includes those patients in whom compression 

1 Among the many forms of tremor which have been described, are also 
the groups, cerebral tremor and the so-called cerebral form of toxic tremor. 



66 CURRENT LITERATURE 

gave a positive result. By this the author means that the spasms imme- 
diately decreased in force, or ceased altogether after the application, by 
means of a regular grip, of pressure on the designated spot. If the 
pressure is applied for only a short time, the tremor usually returns; a 
somewhat longer application of pressure on the other hand stops the 
tremor definitely. 

The other group includes cases in which the results were not decid- 
edly positive, and the narcosis spasms possibly ceased of themselves, or 
circumstances rendered the investigation incomplete. 

Finally come the cases in which compression was ineffective. In the 
33 cases mentioned the measure was used 29 times ; 4 patients had short 
spasms which ceased of themselves and did not call for treatment. 

The other 29 cases fall into three groups as follows: In Group 1, the 
effect was certain in 19 cases; in Group II, the effect was uncertain in 
5 cases; in Group III the effect was nil in 5 cases. 

In no way does the result vary in so far as the degree of uncon- 
sciousness is concerned nor does the result bear any relation to the dura- 
tion of the narcosis. 

The technique used in exerting the pressure is extremely simple. In 
the position in which the narcosis nurse generally sits it is perhaps diffi- 
cult for her to apply a sufficiently powerful downward pressure in the 
carotid fossa. It is easier to apply pressure in this region if one stands 
at one side of the patient and turns his head over toward the other side. 

There is still a question, however, as to whether compression of the 
"blood vessel is the principal requisite. In order to ascertain if this is 
so Rietz has pressed hard, for instance, on the nerves of the axilla and 
has sought, by other means which affect the centripetal nerves and pro- 
duce pain, to obtain the same result as by the method described. All 
such experiments have given absolutely negative results. [Author's 
abstract.] 

Craigie, E. H. The Relative Vascularity of Various Parts of the 
Central Nervous System of the Albino Rat. [Journ. Comp. 
Neurol., 1920, XXXI, June, 429.] 

Craigie has made anatomical measurements of the capillary richness 
in twenty-one regions arbitrarily selected in the spinal cord, bulb and 
cerebellum of the albino rat and has presented their ratios in tabular 
and graphic form. He believes that these values really show in a fairly 
reliable manner the relative richness of the capillary supply. His results 
are as follows: (1) the gray matter is much more richly supplied with 
capillaries than is the white matter, the poorest of the gray being nearly 
half as rich again as the richest part of white among the regions studied ; 
(2) all parts of the white matter are not equally vascular, the pyramidal 
tract, the richest part of the spinal cord, being about twice as rich as the 
fasciculus cuneatus. while the fasciculus longitudinalis dorsalis in the 
bulb is still richer; (3) the gray centers can be sharply divided into two 



SENSORIMOTOR NEUROLOGY 67 

groups, the motor nuclei and the sensory and correlation centers, of 
which the latter are richer than the former. Though the richest motor 
region (ventral cornu) is but little poorer than the poorest sensory one 
(spinal V nucleus), the two groups do not overlap in the case of those 
regions studied, except in a few individuals. The substantia gelatinosa 
Rolandi of the spinal cord is the only part which does not conform with 
this statement; (4) the richest of the centers observed is the dorsal 
cochlear nucleus which is more than half as rich again as the ventral 
cornu, about two and a half times as rich as the substantia gelatinosa 
Rolandi (the poorest gray region), and eight times as rich as the fascicu- 
lus cuneatus; (5) great individual variations occur, and the two sexes 
do not seem to show any constant difference. [Leonard T. Kidd, Lon- 
don, England.] 

Abt, T. A., and Tumpeer, I. H. Significance of Xanthochromia of 
Cerebrospinal Fluid. [Am. Jl. of Dis. of Child., September, 1920.] 
Canthochromia occurred in an infant of eight months who lived 
thirty-seven days. There was marked internal hydrocephalus, pyelitis 
and bronchopneumonia. The yellow C. S. F. was attributed to a men- 
ingoencephalitis with subpial hemorrhage. 

Coupin, F. Absence of the Foramina of Magendie and of Luschka 
in Some Mammals. [Compt. rend. Soc. de Biol., 1920, LXXXIII, 
June 26, p. 954 (4 figs.).] 

The existence of the median foramen of Magendie and of the lateral 
foramina of Luschka in man has been denied by some anatomists. 
Coupin has examined mice, rats, guinea pigs and young cats and rabbits. 
He regards the conclusions drawn from the method of colored injections 
on living animals as unreliable, and also those made postmortem; the 
roof of the fourth ventricle is very fragile, so that one cannot exclude 
the possibility of its rupture by the injected fluid. So he has used dis- 
sections and necroscopical sections. If care be taken to avoid traction 
on bulb and cerebellum, one sees complete continuity of the ventricular 
roof, and there is no visible perforation in the calamus scriptorius region. 
Study of serial sections shows also absence of Luschka's foramina; in 
the lateral recess of the bulb the epithelium of the choroid plexus is 
seen to be continuous with the ependymal epithelium. Thus, the fourth 
ventricle is everywhere limited by an epithelium, and these co-called 
foramina are artefacts. In all the mammals studied Coupin finds that 
there is no direct communication between the ventricular cavity and the 
subarachnoid spaces. [Leonard J. Kidd, London, England.] 

del Rio-Hortega, P. Transformation of the Microglia. [Arch, de 
Neurobiologia, June, 1920.] 

This well illustrated study of the normal and pathologic microglia 
showing the transformation of the branched glia cells into long drawn 



68 CURRENT LITERATURE 

out, rodlike shapes and granule cells and throws light, the author thinks, 
on the so-called rod-cells of Alzheimer. The most striking specimens of 
these rod-cells were from paretics. 

Weed, L. H. The Cells of the Arachnoid. [Bull. Johns Hopkins 
Hosp., October, 1920.] 

Lewis H. Weed discusses the general morphology of the cells lining 
the subarachnoid space; changes in the cells under physiological activ- 
ity; changes in arachnoid cells conditions by age and ultimate changes 
in the arachnoid cell-clusters. From his studies he concludes that the 
arachnoid mesothelial cells are normally of a low, flat type, but their 
morphology depends upon the particular physiological state of the cells 
at the time of examination. Under the stimulus of particulate matter 
and in acute infections, the cells increase in size, become phagocytic 
and at times form free-moving macrophages. Other changes in the 
growth of the arachnoid cells lead to the almost invariable formation, 
in the older animals, of cell-clusters, slowly progressive overgrowths, 
at times undergoing calcification and less frequently seemingly related 
to the formation of endotheliomata. Hence, the morphology of the cells 
of the arachnoid may be said to depend not only upon the location of 
cells (as on the membrane or in an intradural cell-column) and upon 
the physiological state of the cells (as under the stimulus of particular 
matter and infection), but upon the age-condition of the animal (as in 
the arachnoid cell-cluster). [Med. Rec] 

Meyer, A. Herniation of Brain. [Am. Arch. Neur. and Psych., Oc- 
tober, 1920. J. A. M. A.] 

Cases illustrating various types of herniation under the falx and 
under the tentorium and into the foramen magnum are recorded by 
Meyer. They give an interesting quasi-experimental picture of the 
topography and at least in two instances collateral consequences of 
possible importance among the so-called distant symptoms of brain tu- 
mor. One case of glioma of the left opercular region, shows, besides a 
moderate cerebellar wedging into the foramen magnum, a characteristic 
sagittal " tentorial line " on the left uncus, not to be taken for a sulcus 
semi-annularis Retzius. A glioma of the anterior and middle hindbrain 
segment showed similar tentorial lines dues to slight hydrocephalus. A 
most extensive prolapsing glioma of the left temporal lobe with death in 
coma showed a frontal herniation under the falx and a marked sub- 
tentorial herniation of the uncus. A cancer metatasis with a cyst in 
front of the paracentral lobule lead to herniation of the fornicate gyrus 
under the falx and subtentorial herniation of the uncus. A cancer 
metastasis with a cyst in front of the paracentral lobule lead to hernia- 
tion of the fornicate gyrus under the falx and subtentorial herniation 
of part of the uncus and of both subicula, with a striking impingement 
on the calcarine branch of the posterior cerebral artery and collapse of 



SENSORIMOTOR NEUROLOGY 69 

the corresponding part of the occipitatemporal cortex; hence providing 
a foundation for hemianopsia. An aneurysm of the circle of Willis just 
in front of the optic tract and chiasma impinged on the circulation of 
the right hemisphere, with swelling of the right hemisphere without 
actual softening or infarction, but marked herniation of the subiculum; 
left hemiplegia and hemianesthesia, three days later coma, and nine days 
later death. An hemorrhagic cancer metastasis in the right postcentral 
gyrus led to subtentorial herniation and to wedging of the cerebellum. 
An unusually great subtentorial herniation occurred in a case with a 
cystic glioma extending from the right frontal lobe to the right occipital 
lobe, without, however, occluding the calcarine artery. Wedging of the 
cerebellum was added as a secondary consequence. A cancer metastasis 
in the inferior semilunar lobule of the cerebellar hemisphere led to cere- 
bellar herniation into the foramen magnum and to an interesting supra- 
tentorial distention of the region of the splenium, with death eight days 
after a subtemporal decompression. Moderate wedging of the cerebel- 
lum in a child of ten months, with convulsions and brain swelling, but no 
focal lesion, led to a case of marked wedging of the cerebllum, distention 
of the hindbrain and forebrain ventricle; severe frontal headache, lum- 
bar puncture, followed by aggravation and disturbed vision and death 
in three weeks. A suspicion that herniations of the subiculum might be 
responsible for the sclerosis of the cornu ammonis in epilepsy through 
the effects of transitory subtentorial herniation is not, so far, corrobo- 
rated bv this series of cases. 



Booft IReviews 



Berman, Louis. The Glands Regulating Personality. The 
Macmillan Co., New York. 

This fascinating volume conies as almost the first attempt to 
formulate a complete synthetic psychosomatic view of the personality. 
Heretofore many one-sided presentations of the personality have been 
presented. Loeb would attempt a tropistic synthesis ; the behaviorists 
a historical experimental viewpoint; the out-and-out spiritualists a 
purely psychical or transcendental definition. 

The author here believes that a synthesis of clinical, chemical, 
physiological and pathological endocrinology in coordinated activities 
with the vegetative nervous system is capable of providing an ade- 
quate material for synthesis and for a working hypothesis. The re- 
viewer believes he has not only in a most readable manner advanced 
his thesis, but that with true scientific imagination has effected a 
number of most fruitful hypotheses. It is apparent that a true 
dynamic constellation pathology is being attempted, and from many 
sides. Kraus in his General Pathology of the Personality, JellifFe 
and White in their Diseases of the Nervous System, Biedl in Endo- 
crinology, Ritter, Bauer, Tendeloo, Lubarsch and many others too 
numerous to mention in all fields of scientific activity are hot on the 
trail of trying to understand the workings of the organism as a whole. 
The day of static, descriptive pathology of this organ or that organ 
has gone by ; organization, interlocking directorates, synthesis, work- 
ing toward some teleological aim, this is the more satisfactory con- 
stellation, pathology's ideal. 

Berwin arranges his mosaic on an endocrinological framework. 
His speculative ideas are suggestive and we believe useful. We feel 
in one respect that criticism may be advantageously applied. There 
is too much emphasis laid upon really a limited group of what after 
all are purely somatic chemical factors. Important though they may 
be as phyletic inheritance determiners, this is only one side of the 
picture. Kappers has shown the transcendent importance of neuro- 
biologic factors as influencing somatic characters. Environmental 
stimuli, then, must not be neglected. They represent the opposing 
pole, the ambivalent mechanisms, to the somatic phyletic heritage. 
Most important of these for mankind are the sociotropic stimuli 
making for the civilization and culture of the present and for future 
generations. While Berwin has not entirely left these out of ac- 
count, particularly as they are valuated in the important Freudian 
hypotheses, we still believe that he has clung a little too tenaciously 
to the machine that carries on the job, and not enough to the purposes 
to which the machine may be applied. The endocrines are servants 
of the nervous system. They are not its masters. 

70 



BOOK REVIEWS 7i 

Notwithstanding our divergence from the author as to where the 
chief accent should be laid, we hold he has given us a most important 
piece of work — which, differing in its mode of presentation from 
most works of the kind in its easy readability, enhances rather than 
detracts from its value. It is a distinct contribution to the building 
up of a constellation pathology toward which the hopes of the future 
are directed. 

Harrow, B. From Newton to Einstein. D. van Nostrand, New 
York. $1.00. 

For a handy short and readable account of what Einstein's rela- 
tivity theory really is, what it attempts to accomplish, and how well 
it may be said to answer certain heretofore irreconcilable mathemati- 
cal problems, questions concerning the nature of time, of space, and 
of gravitation and the fourth dimension, this handy volume, now in 
its second edition, can be most heartily recommended. 

Hutchinson, J. Facial Neuralgia and its Treatment. W. 
Wood & Co., New York. 

The author here revises and puts into a more useful form his 
excellent monograph of 191 5. He treats in a full and very readable 
manner the various methods of handling trigeminal neuralgia in all 
of its many forms. Alcohol injection methods are freely discussed 
and his reasons stated for his preference for gasserian section given. 
It is an admirable short treatise. 

Whitaker, J. R. Anatomy of the Brain and Spinal Cord. E. 
and S. Livingstone, 17 Teviot Place, Edinburgh. 

This is the fifth edition of this handy short account of the Anat- 
omy of the Brain and Spinal Cord. With the increasing importance 
which is making itself felt in the direction of dynamic neurology this 
cut and dried method of handling the nervous system is becoming 
displaced by a more vital and physiological anatomy, yet as this is 
more or less of a dissector's manual the old-fashioned static descrip- 
tive anatomy may be allowed to have some use. Of the works of its 
kind it is excellent. The illustrations are useful. 

Pfeifer, Richard A. Myelogenetiscii-anatomische Untersuch- 

UNGEN UBER DAS KORTICALE ENDE DER HoRLEITUNG. B. G. 

Teubner, Leipzig. 

Pfeifer here, following the general methods that Flechsig has 
originated and carried out in the brain-anatomical institute of the 
Leipzig Psychiatric Clinic, has offered a reconstruction of the cortical 
ends of the auditory pathways. He shows that the general law of 
Flechsig holds true for the auditory system as well as for others, 
namely, that the projection systems of the sensory pathways are 
myelinated earlier than the association systems. The cortical area 
for the auditory function lies. in a portion of the temporal lobe lying 



72 BOOK REVIEWS 

hidden in the Sylvian fissure. It constitutes but a small part of the 
entire cortical superficial area — about 2 per cent. — and certain vari- 
ations with reference to localization are pointed out. Pfeifer is not 
opposed to criticize Brodman's topographical cytoteconic ideas. The 
general light thrown upon the phyletic development is of interest. 
Some of the conclusions to which he comes are as follows : ( i ) The 
anterior transverse gyrus of the temporal lobes possesses an individual 
projection system; (2) there is sufficient evidence to show that this 
projection system belongs for the most part to the auditory apparatus ; 
(3) this projection system is demonstrated by serial section to be a 
closed system; (4) in the course of the phyletic development a twist- 
ing has taken place in the course of the fibers from the internal 
geniculate to the tegmentum, thus explaining the anomolous relations 
of the auditory pathways to the internal capsule; (5) the auditory 
pathways enter in large curves from front below into the transverse 
convolution and only the median portion runs in the white matter the 
length of the transverse gyrus; (6) thus the anatomical basis of sen- 
sory aphasia has a new basis; (7) Henschen's theories appear in a 
new light, since the precise relations of the pathways to the cortex 
must be viewed in a different manner ; (8) variations in the anterior 
entering auditory pathways vary considerably, enabling Pfeifer to 
mark off two types of central convolution — the steep and the flat ; 
(9) all cases of amnesia from so-called parietal pole foci need to be 
revised to see if auditory pathways are not involved; (10) the great 
variability of the end district of the auditory system, determined 
chiefly by the position of the transverse convolution, makes it impos- 
sible to state that the auditory zone occupies one third of the temporal 
lobes. There is a possibility in the steep type that the middle third 
of the first temporal convolution will lie outside of the hearing end- 
ings. In flat types of the temporal convolutions deep-lying foci may 
leave the auditory pathways undisturbed even when occupying the 
general region of the anterior third of the first temporal convolution. 
The association sphere — planum temporale — acquires a new signifi- 
cance from these researches. 

This short study is a sincere and valuable contribution to our 
knowledge of the development of the auditory projection system. 

Jelliffe 

Rixon, C. H. L., and Matthew, D. Anxiety Hysteria. Paul B. 

Hoeber, New York. 

This we hold is a readable little book upon some of the manifesta- 
tions of repression and conversion mechanisms of Freud as applied 
in a hazy, unsystematic manner to the study of some examples of the 
war neuroses. The author borrows fragments of the Freudian psy- 
chology, but says he does not use it because it connotes pansexualism, 
which general viewpoint he shares with many others. With them 
also he shares the universal cowardice of human beings to face reality 
and the characteristic hypocrisy of the politician who plays up to 
popular prejudices to get the votes. The book contains nothing save 
to the novice, albeit well put with a smattering of MacDougal and his 



BOOK REVIEWS 73 

seven instincts. Why he should call it " modern " views on some 
neuroses it is difficult to understand. 

Monrad-Krohn. Clinical Examination of the Nervous System. 

H. K. Lewis & Co., London. 

This small sketch of 135 pages is a very orderly systematic pres- 
entation of a less than minimum requirement in modern neuro- 
psychiatric practice. It is quite practical and could be utilized to 
advantage for an introduction to case examination of medical students 
or to medical practitioners who want a simple series of formulae for 
examining the sensori-motor functions of the nervous system. 

Nonne, Max. Syphilis und Nervensystem. Yierte Auflage. S. 
Karger, Berlin. 

This, the fourth edition of Nonne's valuable series of lectures on 
neurosyphilis, comes after five years of the war during which all 
European medical energies were focussed upon but one objective. 
Nevertheless neurosyphilis is such a large subject that we must always 
have it under observation, and the war only brought old problems, 
especially those relating to paresis, fatigue, trauma, etc., to the fore. 

X( nine has not changed the character of the book. He has revised 
it most conscientiously and added much from the observations of 
others during the past five years, so that it is practically up to date. 
No student of neurosyphilis can neglect this recent contribution. It 
contains a great many new things and revised judgments about older 
ones. Thus the newer malaria infection treatment of paresis is very 
thoroughly discussed, the general verdict being optimistic, but arsenic 
and mercury still remain necessary. 

There are many points that one would like to take up in a review, 
but it is quite impossible. The new edition is a distinct addition. 

Petren, Karl, Faber, Knud, and Hoist, P. F. Larobok Intern 
Medici n. Bd. I-IV. Gyldenalske Boghandel. Kjobenhavn og 
Kristiania. 

We have singled out but three names from this important Skandi- 
navian Textbook of Internal Medicine, although a large number of 
Norwegian, Swedish and Danish authors have contributed to it. 
Bergmark of Upsala, Holmgren of Stockholm, Krabbe of Copen- 
hagen, and K. Petren of Lund are among the neurological contribu- 
tors. It is a monumental work to be completed in four large octavo 
volumes, two of which only have reached the leviewer. Volume I 
deals with Infectious Diseases. 

Intestinal Parasites and Intoxications. — Volume II takes up Res- 
piratory Syndromes, Circulatory Syndromes, Mediastinal Tumors and 
Inflammations, Blood Disorders, the Disorders of the Spleen, and the 
Hemorrhagic Diathesis. 

We will await with much interest the volumes devoted to the 
Nervous System, as the high quality of the work already presented 
indicates valuable contributions to that side of the work that interests 
our readers. 



74 BOOK REVIEWS 

Kraepelin, Emil. Einfuhrung in die psychiatrische Klixik. 
Vierte Auflage. Johann Ambrosius Barth, Leipzig. 

The fourth revised, rewritten and enlarged edition of Kraepelin's 
well-known introduction to clinical psychiatry now appears in three 
compact volumes. The present edition maintains the striking char- 
acter of Kraepelin's clinical descriptive clarity and behavioristic 
observationalism. He is a keen observer of the actions of the men- 
tally ill and has a definite talent for picturing what happens. If this 
were only combined with as deep an intuitive capacity for understand- 
ing more of the why ! But enough is enough and description and 
systematized observation must precede genetic and interpretative 
formulae. It is a masterly expose of clinical psychiatry. y 

Radhakrishnan, S. The Reign of Religion in Contemporary 

Philosophy. Macmillan & Co., London and New York. 

The author is professor of philosophy in the University of My- 
sore, India, and his work is of special interest as a review of occi- 
dental philosophies seen from the background of the eastern training 
and the Oxford traditions. 

The book, as the author states in his preface, attempts to show 
that of the two live philosophies of the present day, pluralistic theism 
and monistic idealism, the latter is the more reasonable as affording 
to the spiritual being of man full satisfaction, moral as well as intel- 
lectual. He believes that systems which play the game fairly, with 
freedom from presuppositions [how biologically possible, he does not 
state] and religious neutrality [how obtainable when religious func- 
tion is so little known?], naturally end in absolute idealism. If they 
lead to other conclusions, he says, one may suspect that the game has 
not been played according to the rules. [Whose rules?] 

Current pluralistic systems, he holds, are the outcome of the inter- 
ference of religious prejudice with the genuine spirit of speculation. 
His reviews of modern philosophical schemes have behind them the 
object of showing how religion in many disguises serves to swerve 
philosophy from the highroad of an absolute security. These reviews 
are made of current schools of philosophical thought. Leibniz's 
Monadism, James Ward and his school, Bergson and Absolute Ideal- 
ism, Pragmatism, The Pluralistic Universe of James, Eucken, Ber- 
trand Russel and the Upanishads and Personal Idealism, these are in 
general the chapter heads under which his most entertaining material 
is arranged. 

The reviewer has read some chapters, skimmed others, and dug 
deep into a few pages, and believes that the neuropsychiater can 
derive much profit from the careful reading of the whole. It is a 
refreshment to have the current philosophies so well presented and a 
great aid to laying aside prejudice to see how religious dogmas clutter 
up our thinking apparatus and how fiercely such religious schemes 
fight to keep the human mind bound to guard it from fears and 
phobias. Only too frequently is the idea rerepresenting itself that 
religion may serve the function of a delusional belief for manv sick 



BOOK REVIEWS 75 

souls. Pure religion, undefined, is not a matter of dogma, nor form, 
this ism or that, but real creative activity going out into social recon- 
struction. Religion as a delusional defense reaction, and thus it func- 
tions for too many, is an index of a sick soul that must be kept in 
line by the fear of God. How all this, as a side issue, appears in 
these most readable pages must be left to the individual imagination. 

Nissl, F., and Alzheimer, A. Histologische und Histopathol- 

ogische Arbeiten uber die Grosshirnrixde. Erganzungs- 

band. Gustav Fischer, Jena, 1921. 

Sixteen years ago this series was founded by these two gifted in- 
vestigators, both of whom have died. This last volume, made possi- 
ble by the publisher, G. Fischer, who has always taken a keen personal 
interest in scientific productions, and through the support of Kraepe- 
lin's newly founded Research Institute, contains two important mono- 
graphic studies — one by Gerhard Creutzfeldt, on a peculiar focal dis- 
ease of the central nervous system, and the other by Hugo Spatz on 
some experimental work on cross-section of the spinal cord, with 
special reference to the reaction of different embryological tissues. A 
complete index of all of the volumes is an indication of the close of 
this series of " Arbeiten." 

Creutzfeldt's study was of a girl in whose family there were two 
idiots, and who began to have an unknown nervous disease at the ajje 
of two, possibly on a constitutional basis. This advanced in steps, 
with longer or shorter remissions. The symptoms were motor irri- 
tative signs, indicative of motor and sensory loss and loss of sensory 
cortical function, but also with signs of involvement of intracerebral 
association pathways (cortico-striato and cortico-thalamic). Added 
to these were mental defects which gradually assumed the character 
of a dementia with an acute amentia type of psychosis at the terminal 
stages with striking psychomotor symptoms. 

Coma epilepticus closed the story. Two types of pathological 
change are recorded : ( 1 ) a progressive, non-inflammatory focal de- 
struction of nerve tissue of the cortex with plasma glia reaction show- 
ing itself in substitute and Abraiim process accompanied by vascular 
proliferation, and (2) an acute diffuse cell disease, leading to the 
falling out of individual cells of the entire central gray substance, with 
or without glia reaction. 

Spatz's study of nearly 400 pages is a complete monograph of an 
experimental research on fully developed and still growing rabbits, 
with the view to determine the different reaction principles governing 
" unripe " and " ripe " tissue elements. These are then compared to 
human pathological problems as seen in porencephaly and in syringo- 
myelia, especially in all those forms in which congenital factors may 
be suspected. The details are too complicated to present here. A 
worthy ending to a most valuable series of Arbeiten. 

Miiller, A. Bismarck, Nietzsche, Scheffel, Morike. Four 
Case HlSTOUES. A. Marcus and E. Webers Verlag, Bonn. 
The author would elucidate the personality of certain well-known 



76 BOOK REVIEWS 

individuals on the basis of their nervous disorders, a topic of peren- 
nial interest, and constituting the gossipy side of this branch of 
biography. 

The reviewer is of the opinion that in the main much of this type 
of work is wide of the mark. The man is not to be interpreted on 
the basis of his illnesses. What they accomplished — if great men — 
has nothing to do with their illness, save in a much more complicated 
manner than is ever presented, save by the studies issuing from the 
psychoanalytic school. These latter studies show how a man's ill- 
nesses may be interpreted as compensating mechanisms chiefly for 
his failures to live to the full the creative capacities imbedded in all 
men. 

This monograph shows no inkling of this general viewpoint, but 
harks back to the " forms of neurasthenia " these men showed. A 
profitless waste of words. 

Dreyfus, Georges L. Isolierte Pupillenstorung uxd Liquor 
Cerebrospinalis. Gustav Fischer, Jena. 

Dreyfus has given us a number of very valuable studies beginning 
as a student in Kraepelin's clinic on dyspepsias and their relation to 
manic depressive psychoses. Since his removal to Frankfurt, now 
10 years ago, he has steadily applied himself to neurosyphilitic re- 
search and made a large number of valuable contributions. 

This small monograph of approximately ioo pages summarizes a 
large number of observations made during this time, chiefly as direc- 
tor of the nervous department of the state hospital Sandhof of Frank- 
furt, a/M. These studies seek to establish chiefly through the evi- 
dence afforded by complete investigations of the cerebrospinal fluid 
the relationships between isolated pupillary changes and syphilis. 
While it has come almost to be a dogma that these pupillary changes 
mean syphilis, the better informed know that such a dogma is false. 
A number of variable factors are possible. Dreyfus here gives a 
thorough analysis of many of these perplexing problems of clinical 
neurology. The monograph is well done and will be found useful. 
There are no new situations which have not already been presented 
by our own neurosyphilitic students, especially Southard's and Solo- 
mon's valuable monograph. Practically only German work is con- 
sidered. 

Cook, William G. H. Insanity and Mental Deficiency in Re- 
lation to Legal Responsibility. E. P. Dutton & Co., New 
York. 

This originally appeared as a thesis for the Degree of Doctor of 
Laws in the London University and as such casts an interesting and 
valuable light on the scope of the English educational schemes for 
the legal profession. 

It deals chiefly with problems of legal responsibility, but from the 
standpoint of English statutes. Inasmuch as many of our own are 
like these, the work can be consulted to advantage here. In the main, 



BOOK REVIEWS 77 

however, the whole problem is "muffed" by the author. He still 
talks about " insanity " as a reality. He does not yet grasp it as a 
legal abstraction only and hence prates about the medical definition. 
There is no medical definition of a legal abstraction. Medicine is 
interested in a group of processes which it terms illnesses, diseases, 
or, in the mental sphere, psychoses. If an individual, by reason of a 
psychosis, comes within the limits of an existing statute, and these 
statutes vary all over the globe in their details, for the purposes of 
law he may be abstractly regarded as " insane," and society can then 
do with his person or his property, or both, what its statutes have 
laid down it could or could not do. If this very simple series of 
notions could be grasped by the legal-minded, much verbiage curtailed 
and misunderstanding could be removed. 

The American Psychiatric Association have come to an under- 
standing of what these psychoses are and have attempted a series of 
limiting descriptive terms so that for their purposes the whole study of 
the psychoses and the many administrative problems involved are made 
more uniform. It is to be regretted that the author knows so little 
of these types of studies and only repeats old, moth-eaten, rubbishy, 
legal conceptions of disease processes and hopes to build up on such 
rotten timber a sound constructive medical jurisprudence. 

So far as he goes his discussions are admirable, but they are so 
useless. 

Lhermitte, J. La Section Totale de la Moelle Dorsale. Im- 

primerie Tardy-Pigelet et Fils, Bourges. 

Among the recent studies devoted to anatomical and clinical spinal- 
cord syndromes this one of Lhermitte's stands out as of striking 
value. This is due not alone to the rich material which the ruthless 
experiments of war have provided, but also to the clinical care with 
which the syndromes have been studied, as well as the patient micro- 
scopical work which has pursued the symptoms to their most logical 
ends. 

These researches have special value in that they have been carried 
out with young healthy individuals who have suddenly acquired their 
injuries. Furthermore, they have been limited to lesions of the 
dorsal cord. In this manner the study of bladder and rectal functions 
can be pursued without the complexities encountered in lesions of the 
lumbar and sacral regions. 

Historical considerations are rapidly summarized, beginning with 
the earlier studies of Brown-Sequard and ending with those of Head 
and Riddoch. Then follow the " Facts," the case histories with 
the anatomical findings. The author brings into relief first a phase 
of shock and then a phase of spinal automatism. These two phases 
present marked contrasts and in the many evolutionary stages between 
them may be found many of the fragmentary formulations with which 
neurological literature has been burdened. 

In Chapter II Lhermitte very clearly summarizes the clinical evi- 
dence of complete interruption. First the phase of shock. Abso- 
lute loss of motility. Complete loss of sensation of all qualities 



78 BOOK REVIEWS 

below the spinal segment wounded. Obscure, unprecise and non- 
localizable subjective sensibility disturbances result from the necessary 
radicular complications. Tendon reflexes are abolished. Muscle 
tonus — the question is uncertain. Cutaneous reflexes are variable. 
Those of the sympathetic are not abolished. The plantar reflex is the 
usual flexor type, and this type, according to Lhermitte, affords evi- 
dence of total section, although he maintains that an extensor response 
should not be held incompatible with total section of the cord in the 
phase of shock. Urinary retention from spasm of the uretro-vesical 
sphincters is the rule, whereas incontinence of feces is more apt to 
occur. The pilomotor and the scrotal reflexes are conserved. Ani- 
drosis is usual, but not absolute. [See Andre Thomas, Le Reflex 
Pilomoteur, 1921.] 

After a variable period the later phase of spinal automatism sets 
in. Flexion movements of defense, massive and violent, set in. 
These may be induced in a great variety of ways. Sensation remains 
abolished, although tuning-fork tests show a loss of bony sensibility 
with often a retention of acoustic perception. Subjective sensations 
of variable quality and character persist and are as yet unanalyzable. 
Vesical power returns. It is of a purely automatic character, how- 
ever. Visceral sensibility remains lost for the most part. Muscle 
tonus may remain normal, or hypertonicity may be present. Certain 
muscle groups show variable tonus characteristics. Certain tendon 
reflexes may return. Skin reflexes may be augmented in the auto- 
matic phase. Lhermitte reports the inversion of the skin plantar 
reflex in four cases histologically verified as total section. In three 
of these the Babinski reflex was unilateral. This section contains an 
admirable resume of the so-called defense reactions and the spon- 
taneous, automatic movements so amply recorded in recent war 
neurology of the spinal cord. The behavior of the bladder and rectal 
sphincters in Lhermitte's experience bears out, in the main, the obser- 
vations of Head and Riddoch. Incontinence is not a pure syndrome. 
The human being does not behave exactly like the experimental ani- 
mal of Sherrington. Spontaneous and regular automatic discharge 
from the bladder is the rule. Rectal automatic discharge tends to 
follow similar principles, but apparently there are complicating fac- 
tors ; but there are also here as yet unanalyzable variations. The 
usually conceived rectal incontinence is a false incontinence. Inter- 
esting facts relative to automatic genital functions are reviewed^ as 
are also circulatory disturbances, edemas, bed sores, sweat mech- 
anisms, which are usually suppressed in the anesthetic areas and con- 
served or exaggerated in the paralyzed segments. The findings of 
Andre Thomas for the vegetative reflexes of the pilomotors, scrotal, 
vasomotor and vascular tensions are verified. 

Lhermitte then considers the terminal or cachetic phase. 

Chapter III is devoted to the pathological findings. The men- 
inges, fiber pathways, gray matter, spinal roots, are all studied by 
the latest best methods. This section is beautifully and exhaustively 
illustrated and a synthesis of the findings presented. 

Finally the physiological pathology is reviewed in a comprehensive 



BOOK REVIEWS 79 

and searching manner. A complete bibliography closes this most 
valuable and thoroughly sincere monograph. 

In closing we congratulate the author upon this splendid piece of 
work, which will remain a mile-stone of progress in our exact knowl- 
edge of the results of total dorsal section of the spinal cord in the 
human being. 

Jelliffe 

Christiansen, Viggo. Les Tumeurs du Cerveau. Masson et Cie., 

Paris. 

Prof. Christiansen, of Copenhagen, has written this very delight- 
ful treatise, which, presented to the French reading public through a 
charming preface by Pierre Marie, appears at the same time a tribute 
to French neurology and a most valuable contribution to medicine. 

It is particularly of interest as a borderland treatise between neu- 
rology and surgery, for the gifted Danish neurologist has collected 
from a large hospital and polyclinic material a rich treasure of obser- 
vations on pure neurology- and applied neurosurgery as well. 

Early diagnosis, exact localization, operative possibilities, these 
are the keynotes in the formation of this volume. Tumors of the 
motor region, of the occipital lobes, base of the brain, of the hypoph- 

. the cerebellopontine angle — an especially interesting chapter 
— peduncular and cerebellar, these are the chapter headings, clos- 
ing with a discussion of uncertain signs and a final chapter on sur- 
gical intervention. A tabular review of 21 cases of radical opera- 
tion constitutes an appendix to this well worth while book. 

Thomson, H. Campbell. Diseases of the Nervous System. Paul 

B. Hoeber, New York. 

The third edition of this most excellent little book is to hand. 
While it belongs to the Quiz Compend group, it is so much superior 
to this type of examination pick-me-ups that it is worth special praise, 
even though it tends to perpetuate a type of neurology which has 
ceased to function except as a business enterprise. 

Cohn, Toby. Leitfaden der Elektrodiagnostik und Elektro- 

therapie. S. Karger, Berlin. 

This is the sixth edition of this one of the most comprehensive of 
this type of work. It is not a reprinting of previous editions. It is 
carefully revised and the newer researches on electrical forces in- 
cluded. We know of no better work in German at the present time. 

Liepmann, W. Psychologie der Frau. Urban und Schwarzen- 

berg, Vienna and Berlin. 

In ten lectures, here gathered together in a big octavo of 300 pages, 
the author offers a contribution to a synthetic psychosexual under- 
standing of the female. Inasmuch as the woman's movement has 
gained such headway throughout the world, he believes it important 
(high time) to gain a better insight into the psychological variations 
of man and woman. 



8o BOOK REVIEWS 

The way is long — Heraclitus, he points out, grasped the immensity 
of trying to understand the deep pathways of the evolution of the 
human being — and he traces sketchily and interestingly a few histori- 
cal fragments wherein are written down different attacks upon the 
problem. Biological mechanisms destined for carrying on life proc- 
esses are then taken up, with a discussion of animal behavior in rela- 
tionship to the reproductive instinct following. More complicated 
situations of the same nature in man are then discussed. Then follow 
chapters on prostitution and general deductions. The author's whole 
psychology is based on the general questionnaire method. He puts 
down as facts what people tell him. He has no notion whatever what 
an enormous amount of distortion of evidence surrounds the whole 
problem. It is an interesting but superficial book and just like all of 
the rest of the books upon the sexual instinct until Freud showed 
something deeper and more trustworthy. 

Kraepelin, E. Arbeiten aus der Deutschen Forschungs, ans- 

TALT FUR PSYCHIATRIE IN MlJNCHEN. II & III Band. Julius 

Springer, 1921. 

This second volume of collected studies from Kraepelin's newly 
founded Research Institute for Psychiatry contains a large number 
of contributions showing that in spite of the hard times in Germany 
the Munich clinic is still active and doing good work. Volume III 
consists of a reprint of Spatz's work from the last volume of Alz- 
heimer and Nissl's series, noted elsewhere. 

Espejo, Luis D. El Lexguaje Normal y Patolojico. Sanmarti 

y Co., Lima. 

In an extremely readable and well-developed argument the author 
traces the evolution of language through mimicry, gesture, musical 
intonation, rhythm, to its higher forms as elucidated by its major 
modifications in aphasia. 

Space does not permit him to round out the entire account, nor us 
to speak of the many features of this admirable presentation. 

Fredericq, L., et Nuel, J. P. Elements de Physiologie Humaine. 

Masson et Cie., Paris. 

This is the seventh edition of a student's handbook of physiology. 
Whereas the neuropsychiatrist can find all of this material nearer at 
hand and in English, should he wish to read a very delightful physi- 
ology in French, he will find this one of the very best. 

Adler, Alfred. Das Problem der Homosexualitat. E. Rein- 

hardt, Munich. 

Adler's short study of 50 pages is a general reiteration of his 
doctrine of the ego effort for power. Man's cowardice and wish for 
power makes him fear the female. In life he conquers by being a 
despot and homosexual. While there are many striking features in 
this short study, it does not go deep enough into the infantile sexual 
factors to be a satisfactory hypothesis. 



1\ 

VOL. ss. FEBRUARY, 1922. No. 2. 

The Journal 

OF 

Nervous and Mental Disease 

An American Journal of Neurology and Psychiatry, Founded in 1874 



Original Articles 



OCCIPITAL LOBE EMBOLISM. 
By Andrew H. Woods, M.D., 

HEAD OF THE DIVISION OF NEUROLOGY IN THE DEPARTMENT OF MEDICINE, PEKING 
UNION MEDICAL COLLEGE, PEKING, CHINA. 

Origtn of Cerebral Emboli. 

Particles can be swept into the brcin by the arterial blood from 
any part of the effluent vessels of the lungs, from the heart, or the 
arteries leading from it to the brsin. The emboK may be particles 
derived from diseased intima, vegetations from heart-valves, broken 
down atheromatous patches, detached bits of thrombus, parasites, or, 
finally, material injected into an artery by the erosion of an abscess 
or tumor through its wall. Cerebral emboli most frequently have 
their origin in the heart, being products of valvulitis or of thrombi 
formed when the circulation is slow. Less frequently they are pro- 
duced by purulent involvement of the great arteries. 

Bone-disease in the neighborhood of an arterial trunk presents 
conditions favorable for thrombosis and embolus-formation. The 
vertebral artery in passing through the costo-transverse foramina of 
the upper cervical vertebrae, and in winding around the articular 
process of the atlas, would be almost necessarily involved in even 
a small area of osteo-periostitis of that region. The walls of blood 
vessels resemble the dura mater in being resistant to invasion by 
tuberculous or purulent processes. Yet micro-organisms do find en- 
trance by way of the lymphatics of the arterial walls and thus reach 
the intima, causing endarteritis with localized inflammatory accumu- 
lations, or massive stoppage of the vessel. Thus a nest is prepared 

81 



82 ANDREW H. WOODS 

from which emboli easily take their origin. In the following case 
the cerebral embolism probably originated in that way. 

Case 1. 

Summary: — A left sided, deep inflammatory focus in the region of the 
upper cervical vertebrae, a traumatic disturbance of that region, immediate 
paresthesia and weakness in the two left limbs and sudden loss of vision in 
the fields subserved by the calcarine region of the left occipital cortex. 
Recovery of function in the lower quadrant field. 

This patient, referred by Dr. Dwight Sloan of Nanking, and re- 
cently examined by me in consultation with Dr. Harvey J. Howard, 
was a young woman of 30 years, who in November, 1920, suffered 
pain and stiffness in the left side of the neck. She applied to an 
osteopath for relief on the twentieth of December. The bending 
and twisting operations of the first seance caused great pain in the 
neck, which was suddenly followed by nausea and dizziness. Dur- 
ing the treatment the patient says her left arm felt a little numb and 
weak. Afterwards she vomited. The discomfort continued for the 
succeeding two days, but the osteopath nevertheless proceeded on 
the twenty-second of December to give an equally strenuous treat- 
ment. After twenty minutes the patient's left upper and lower ex- 
tremities became numb ("pins and needles") and "felt asleep." 
The left upper limb in addition felt " weak and awkward when 
moved." The tingling ceased after a few minutes, but the numbness 
lasted several days ; the weakness and awkwardness, two weeks. 
During this second seance the patient suddenly became conscious 
" of a dense black shadow obscuring every thing on the right side." 
An examination by Dr. Clapp, of Shanghai, on the tenth of January, 
showed that at that time complete right-sided hemianopsia existed. 
As a matter of osteopathic psychology it is interesting to note that 
the manipulations were continued until the thirtieth of January. At 
that time the patient says there persisted " a hard, tight, stiff feeling 
at the back of the neck on the left side up near the base of the skull, 
with the black curtain on the right half covering everything." 

On March 2nd, Dr. Howard recorded: — "Fields for form, red, 
and green, taken, showing a right homonymous upper quadrant 
anopsia. There is in addition a contraction of the form-fields in all 
quadrants as compared with the field of average persons. The fundus 
is normal. Illumination of the blind halves of the retinae was fol- 
lowed by pupillary reaction." 

My neurological examination, the 26th of March, showed: — Right 
homonymous upper quadrant anopsia. The scotoma, according to 
Dr. Howard's chart (Fig. 1), extends from the zero-point through 



OCCIPITAL LOBE EMBOLISM 



«J 



the upper quadrant down to a radius 105 from the zenith. Its 
border passes almost exactly through the center of the macular field. 
Seventy-five degrees of the lower right quadrant field have there- 
fore recovered vision. There is a slight headache, but no other sub- 
jective disturbance. Minute examination of all qualities of objective 
sensation shows that there is no disturbance in the region supplied 
by the upper cervical nerves of either side. The limbs and trunk 
show normal perception of touch, pin-prick, heat, cold, vibration, and 
joint movements. There is no fault in her orientation or appreciation 
of distance, perspective, stereognosis, or of the significance of visual 
or auditory perceptions. 

The muscular power in all regions is normal. All tendon reflexes 
are prompt, those of the lower limb being slightly more so than the 
corresponding reflexes of the right side. (The left knee-jerks were 




Fi<:. 1. Dr. Howard's field-chart of the first patient, March 2nd, showing 
105° sector-anopsia and concentric restriction of vision. 

reported by Dr. Sloan as more prompt than the right in January). 
There is no difference in the fatigibility of the limbs. The sphincters 
are normal ; gait and station show no defect and there is no fault in 
the coordination of other voluntary or involuntary muscle-move- 
ments. The ciliospinal and vasomotor functions are undisturbed. 
Spinal puncture gave a normal fluid, without tubercle or other 
organisms, and giving a negative Wasserman reaction. 

A physical examination by Dr. McLean showed that the tonsils 
and lungs were not diseased. The first heart sound at the apex was 
roughened ; sounds at the base were clear ; borders normal. The 
pulse was slow, blood pressure was 1 14/70. The kidneys, other 
abdominal organs and the blood-picture were normal. 

Pressure upon the tip of the left first and second tranverse proc- 
esses gave pain ; and palpation in that region gave the impression of 
increased resistance in the soft tissues of the left suboccipital region 



84 



ANDREW H. WOODS 



behind the mastoid process. Pressure upon the occipital scalp gave 
no sign of nerve-tenderness. Bending the neck to the right caused 
pain in the left suboccipital region. Rotation either way caused the 
same discomfort. Rocking the head anteroposteriorly did not cause 
pain nor did driving the vertebrae together by impact upon head or 
heels. The roentgen-ray report by Dr. Hodges was negative except 
for a slight deepening of the shadow of the peri-vertebral tissues 
ventral to and to the left of the atlas and axis. Her teeth were 
practically normal. A tuberculin test made by Dr. Korns with 
gradually increased doses of Koch's old tuberculin (o.i up to 
lOmg.) at 48 hours intervals gave no reaction. 

Case 2. 

Summary: — Slight valvular heart disease, sudden dizziness, hemianopsia, 
visual paresthesia, tingling in extremities, some disorientation. Later, partial 
recovery of visual fields. 

The second patient was a healthy man fifty years of age, who 
while riding horse-back was suddenly seized with dizziness, frontal 




Fig. 2. Dr. Howard's first, second and third field-charts of the second 
patient, showing apparent invasion of the normal field at first examina- 
tion, the amount of recovery in 11 days, and the concentric restriction of 
vision. (Only the chart of the left eye reproduced.) 

pain, and a momentary tingling in the left fingers and toes. He felt 
as if a strong light were falling upon his eyes from above, and sup- 
posed his visored cap had blown off. There was an immediate left 
homonymous hemianopsia, complete at first, but on the eleventh day 
beginning to clear up in the peripheral zone and in thin sectors in 
both upper and lower quadrants near the vertical meridian. The 
scotoma extended to the fixation point (Fig. 2). Evidences of val- 
vular heart disease were found on examination. Excepting the eye- 
condition noted above he was neurologically normal. 

The patient immediately after the mishap dismounted, called a 
jinrickshaw and directed the coolie to take him home. Although the 
road was familiar he guided the man wrongly, but after some hesi- 
tation got him to the right road and reached home. He complained 



OCCIPITAL LOBE EMBOLISM 85' 

while in the hospital of inability to think of his office and of room? : 
in his house because he could not " get the positions of the furniture 
straight." A month after his discharge he would on occasions find 
hmself farther along the street than he intended to go. But from 
the first there was no flaw in his visual or his manual stereognostic 
discrimination. (This patient was also referred to me by Dr. 
Howard.) 

Prognosis 

The prognosis in cerebral embolism depends upon the immediate 
cerebral lesion, the nature of associated lesions of other parts, and 
the gravity of the condition out of which the embolism sprang. For 
these patients it is guardedly favorable so far as farther damage to 
the cortex is concerned. If an embolus contains tubercle bacilli, 
trouble may follow, since solitary or massed tuberculous nodules in 
nervous tissue develop from infected particles carried by the blood. 
Iii both patients, however, the inflammatory processes were probably 
pyogenic. 

Tuberculous spondylitis in the neck is fortunately rare. Buzzard 
says that the involvement of the atlas or axis is tuberculous in one 
per cent of all cervical cases. In a fatal case recently reported by 
Rumke the patient had presented signs only of occipital neuralgia 
with negative X-ray findings. Death followed suddenly. The 
autopsy showed tuberculous osteitis of the upper vertebrae. 

Traumatic cervical spondylitis, with or without invasion by pus 
or other bacteria, is relatively frequent ; and spondylitis from what- 
ever cause is much more dangerous when it occurs in the neck than 
when found lower down because of the danger of dislocation or of 
involvement of the respiratory and vaso-motor centers, or, by up- 
ward extension, of the medulla-oblongata. But fortunately in many 
of these patients, whether the infection is due to tubercle or other 
bacteria, recovery occurs, often rapidly, even when all the symptoms 
are grave. Buzzard was " impressed with the power of recovery ex- 
hibited by some cervical cases, especially in young people," and adds, 
" there is no disease of the [spinal] cord in which symptoms of 
equal gravity so often pass away." 

The Route of an Embolus. 

Since more cerebral emboli lodge in the left than in the right cere- 
bral hemisphere the commonest route is probably through the left 
internal carotid artery. Emboli found in the posterior cerebral dis- 
tribution may conceivably have arrived either through the carotids 
or the vertebrals, for it is probable that with the typical arrange- 



86 ANDREW H. WOODS 

ment of the circle of Willis the current through the posterior com- 
municating arteries is sometimes forward, sometimes backward, de- 
pending upon the varying demands for blood in the anteriod and the 
posterior parts of the hemispheres. A single case with the source of 
the embolus along the carotid artery and showing an embolic lesion 
in the occipital lobe, would give direct evidence upon this point. But 
I have found no pertinent case in the literature. Stengel states that 
emboli may travel back from the carotid to the posterior cerebral 
artery, but cites no cases. 

Simultaneous Sensory and Motor Long Tract Disturbances. 

At the time of onset there appeared in the first patient, ( I ) weak- 
ness and awkwardness of the left upper extremity which persisted 
for two weeks after the traumatism; (2) tingling and numbness in 
the left upper and lower extremities, but not in the face, immedi- 
ately after the violent wrench. The tingling disappeared after a few 
minutes, but the numbness lasted several days. These motor and 
sensory symptoms were on the same side (left) as the inflammatory 
lesion in the neck, and were, therefore, due to local disturbance of the 
left spinal tracts, since there is no reason to suppose that trouble had 
occurred on the right side above the decussations. 

The immediate mechanism of the track irritation may have been 
through disturbance of the local blood-supply of the cervical cord or 
through merely mechanical action. The particular sensory bundle 
irritated was probably the dorsal tract, since involvement of the 
spino-thalamic tract at the level would have given paresthesia re- 
ferred to the opposite limbs. The awkwardness and weakness of 
the left upper extremity with increased tendon-jerks points to dis- 
turbance of the left pyramidal tracts. 

In the second patient simultaneously with an embolic lesion of the 
right visual cortex there occurred tingling in the left limbs. In a 
case of right occipital lobe involvement recorded by Beevor and 
Collier paresthetic phenomena similar to those in our patients had 
occurred in the left arm for several months before the arterial oc- 
clusion. Their patient was arterio-sclerotic, and the pulvinar of the 
right thalamus was found at necropsy to be affected as well as the 
right visual cortex. In this man as in our second patient the seat 
of the disturbance responsible for the paresthesia was presumably in 
the upper sensory tracts in the right thalamic region, which also are 
supplied by the posterior cerebral artery. 

The cortical phenomena exhibited by these patients raise several 
questions regarding the topography of the visual area in the occi- 
pital lobe. 



OCCIPITAL LOBE EMBOLISM 



87 



Are There Bilateral Cortical Connections for Each Macula? 

The line of separation between the dark and the bright fields in 
each patient ran through the macula, which was therefore divided 
like the other parts of the retina into a blind and a seeing side. The 
undamaged visual cortex of the other hemisphere did not provide 
functioning connections for the hemi-maculae of the hemianopic 
fields. Gowers and others supposed that such bilateral innervation 
obtained. Dr. Howard's charts accord with the contrary con- 
clusions, i. e., that the right half of each macula sends its fibers only 
to the right occipital cortex ; the left half, only to the left occipital 
cortex. 

Related Areas of Retina and Visual Cortex. 

One of the earliest case-reports that shows which retinal and 
cortical areas are functionally related was that of Beevor and Col- 




(B) 



M, at occipital pole, area of macular representation. 

C C B, depth of calcarine and post-calcarine fissures, containing 

arteries. 
Represents superficial edges of same. Fissures here drawn 

as if stretched out into one plane. 
|-|-|-|-| Represents borders of area-striata, left hemisphere. 
(Diagram made from a dissection after gelatine injection.) 
Right visual field. The numerals indicate the parts of the field 

that are obliterated when the areas of the occipital cortex 

correspondingly numbered are destroyed. According to 

Holmes' topography. 



Her (19x54), referred to above, whose patient, a workman 55 years 
old, had formication and numbness in his left hand, arm, and face 
during twenty months before a left upper quadrant anopsia de- 
veloped. From time to time after that up to his death attacks of 
unconsciousness preceded by queer behavior occurred. Necropsy 



88 ANDREW H. WOODS 

showed as the chief lesion occlusion of the right posterior calcarine 
artery with resulting necrosis of the lower half of the right visual 
cortex including a small part of the lower cuneal area. The whole 
infolded cortex of the posterior calcarine fissure was destroyed. In 
this case loss of function of the lower right quadrant of each retina 
was associated with necrosis of the lower half of the right visual 
cortex. 

These findings supported Monakow's teaching (1892) that the 
upper half of each visual area functions with the upper half of the 
appropriate retinal areas, the lower half with lower retinal areas. 
Monakow, however, thought the macula might be represented not by 
one circumscribed cortical area but by cells scattered over the whole 
visual cortex. 

Gordon Holmes in 1918 sought to define precisely the reciprocally 
related areas of the retina and the cortex. The numerals superim- 
posed upon the diagram (Fig. 3) indicate at a glance the general 
areas of the cortex and retina thought by Holmes to be mutually 
associated. 

Partial Recovery of Function. 

The insufficiency of the collateral connections of the terminal 
cortical arterioles makes infarction almost inevitable when arterial 
stoppage occurs at any point. Yet the existence of even a slight col- 
lateral blood-supply explains the partial recovery of function by 
some of the affected cells, particularly in areas lying at the periphery 
of the visual area. The revitalized area in our first patient is that 
marked 5, 6, 11, 12, and the parts of M lying adjacent to 5 and 6 
(cf. Figs. 1 and 3 all of which lie near the field of another artery. 
In the second case parts of the corresponding right cortical areas 
marked 7, 8, 9, 10, 11, and 12, (Figs. 2 and 3), recovered function 
progressively for eleven days, after which little additional improve- 
ment occurred. Here the anterior part of the visual area at first 
must have been deprived of blood but afterward regained circulation, 
possibly through the shrinkage or forward movement of the throm- 
bus beyond the points of origin of the branches that nourish those 
areas. 

Recovery of function may occur for other reasons. In traumatic 
cases it may be that concussion depresses the function of some cere- 
bral cells in the zone immediately surrounding the destroyed area, 
and that such function is later regained. The transitory functional 
depression seen in fatigue and in hysteria may be found in traumatic 
or embolic cases in the area surrounding the traumatized region ; for 
upon any traumatic affection of the nervous system a functional ele- 



OCCIPITAL LOBE EMBOLISM 89 

merit is easily superimposed. The peripheral concentric loss in both 
of these patients may prove to be transitory and subject to this ex- 
planation. Intermittent closure of an artery is another cause 
assigned by some writers for recurrent loss and resumption of 
function in the organs which it supplies. If the cause assigned be 
an intermittent vaso-constriction through the va so-motor mechanism, 
such an assumption calls for further confirmation ; but intermittent 
pressure upon blood vessels due to inflammatory processes or tumors 
appear to be a credible explanation. In Stieren's patent an evanes- 
cent restriction of the visual fields is said to have been due to inter- 
mittent pressure upon the (posterior cerebral?) artery by a hypo- 
physeal tumor. 

The apparent extension of the hemiopic scotoma of the second 
patient across the meridian at the time of the first exHrninaloi'i is 
hard to explain unless it was due to the tendency of such patients to 
rotate the eyes conjugately toward the visible field. An image at- 
tracting attention, yet indistinctly perceived by the cortical cells, 
tends to draw the eyes toward it so as to bring it into distinct vision. 
This phenomenon may be due to a reflex actuated within the visual 
cortex and mediated by efferent fibers extending from the occipital 
lobe to the mid-brain centers for conjugate movements. But, how- 
ever produced, the tendency seems to exist, and shows itself in 
patients untrained in perimetric examinations by a shifting of the 
eyes toward objects dimly seen in the visible field, thus apparently 
bringing the border of the scotoma across the meridian. As the test 
object approaches the macular field vision is clearer and the tendency 
is more easily overcome, so that the line curves back at the fixation 
point. 

The slight disturbance of visual orientation in the second patient 
was probably due to ischemia of the convex surface of the occipital 
lobe. But even though a considerable part of the convex surface of 
the right occipitoparietal lobe be destroyed, the disturbance of judg- 
ments based upon perceptions mediated by the area striata is slight 
and transitory, because of the more specialized part played by the 
left hemisphere in such judgments. 

It is probable, then, that in the first patient an embolus lodged in 
the artery supplying the lower half of the area striata. In the 
second patient the stoppage was in the main stem of the posterior 
cerebral artery, the first shock disturbing both the medial and the 
convex surfaces of the occipital lobe, and the post-thalamic sensory 
tracts. The residual necrosis here was of the posterior half of two- 
thirds of the visual area. 



90 ANDREW H. WOODS \ 

REFERENCES 

Rumke, H. : Nederlandsch Tidjdschrift V. Geneeskunde, Dec. 18, 1920. 

Buzzard, E. F. : Osier's Modern Medicine. 

Stengel, A., and Fox, H. : Text-book of Pathology. 

Beevor, C. E., and Collier, J.: Brain, 1904, p. 153. 

v. Monakow : Arch. f. Psych & Nervenk., serial 1889-1893. 

Mairet, A., and Durante, G. : On concentric shrinkage of visual field from 
exhaustion: Presse Med. v. 26, p. 611. See also Wilson's 
article abstracted, Amer. Journ. Ophthal. 1918, p. 138. 

Stieren, E. : Trans. Amer. Acad. Opth. and Otolaryng., 1917-18, p. 45-57 
(abstr. Amer. Jour. Opth. 1918.) 

Holmes, G. : Eye-movements, Brit. Jour. Ophth. June, 1921. 



THE LOSS OF THREE GERMAN INVESTIGATORS, 
ALZHEIMER, BRODMANN, NISSL. 

By Professor Emil Kraepelin 1 
of Munich. 

The mention of the names of Alzheimer, Brodmann and Nissl 
brings before us with a deep sense of pain the great loss which the 
last years have brought to our specialty. Three most highy gifted 
investigators have gone from us, each one in his way irreplaceable, 
all three pioneers in the field of work most important for our further 
knowledge, that which should make clear to us the somatic ground- 
work for mental disturbances. The scientific life work of these 
men is a glorious page in German science the like of which no other 
people can set in comparison with it. It was Nissl, the greatest of 
the three, who, working comprehensively and constructively and 
with steadfast aim, established the premises for a pathological 
anatomy of the brain cortex and endeavored to search out with all 
the aids of scientific technic the structural plan and the meaning of 
the most highly developed tissue of the body. Alzheimer, his most 
loyal pupil and fellow worker, toiled indefatigably with never failing 
patience and self sacrifice to establish, through an endless number of 
individual investigations, the cortical changes corresponding to the 
different forms of mental disturbance. He sought in this way to 
make possible to the clinician in our territory that testing of his 
hypotheses which has shown itself everywhere in medicine as the 
most powerful lever of progress. Brodmann had set himself the 
task of discovering the cell division in the cortex and so prepared 
the soil for that future work which should inform us concerning 
the localized extension of the disease processes in the cortex and 
also the significance of the individual tissue areas attacked by them. 

I cannot undertake to enter into detail in regard to the marvellous 
achievements of our departed colleagues.* What lies upon my heart 
is to show emphatically how unfavorable the conditions have been 
under which those investigators must have had to work. Whoever 
knows the course of their life will think with deep sorrow what 

1 Translated by Louise Brink, A. B., by permission from Munch, med. Woch. 
[* See among others Spielmeyer: Zeitschr. f. d. ges. Neurologie u. Psy- 
chiatric XXXIII, i (Alzheimer) ; Lewandowsky ebenda XXX, 319. (Alzhei- 
mer) ; Vogt: Journal f. Psychologie u. Neurologie XXIV, 5 and 6 (Brod- 
mann); Nissl: Zeitschr. f. d. ges. Neurologie u. Psychologie XLV, 5 Brod- 
mann; Kraepelin. Munch med. Wochensch. 1919, io58 (Nissl).]. 

91 



92 EMIL KRAEPELIN 

irreparable values have been lost with them and with what difficul- 
ties they had to struggle in their labor to make available for the great 
problems of our science the powers which were working creatively 
in them. 

Alzheimer's scientific career began in the year 1889, after all sorts 
of fundamental preparations, when he met Nissl in Frankfurt. He 
was bound to him from that time on, not only in the most zealous 
work together toward common ends but by a close personal friend- 
ship. We may rejoice in that fate which brought together at that 
time these two men who seemed to be destined to open for us the 
way to knowledge of the physical foundations of mental disturbance. 
It was moreover a particularly fortunate circumstance that they 
found in Weigert a sympathetic adviser and in Sioli an institutional 
head who gave support to their scientific efforts. It must not be for- 
gotten, however, that both investigators were naturally institutional 
physicians of the first rank, that they bore upon their shoulders 
exceedingly strenuous and responsible medical duties and that they 
could go to their scientific tasks only after discharging the duties 
which were theirs. A fair estimate of the value of their incomparable 
achievements can be made only when one intimately realizes these 
conditions. It is hardly necessary to explain that under such con- 
ditions not only was it necessary to give up the pleasures of life but 
that very often they played havoc with health and the power for 
work. 

In the year 1895 the exceedingly close and fruitful fellowship in 
their work came to a temporary termination because of Nissl's re- 
moval to Heidelberg. Alzheimer had to take over now more than 
ever the burden of the superintending physician's busy life and the 
management of the institution, because of the work of organization, 
very often claimed his attention. He succeeded, however, through 
his great power for work and his determined industry in accomplish- 
ing the gigantic and fruitful task of an exact research of a large 
number of brain cortices. It was meanwhile not to be mistaken that 
an exceptional ability was interfered with most sensitively in its 
development through the relentless work of every day. 

Alzheimer had meanwhile become scientifically independent, a 
fortunate circumstance, so that he would naturally have had to find 
the way to academic paths. With the assiduity characteristic of him 
he could not attach himself long to these but considered much more 
strongly entry upon the position of institutional head, although I 
earnestly advised him against this. It was a great good fortune for 
him that this enterprise fell through. Through this failure he was 



THE LOSS OF THREE GERMAN INVESTIGATORS 93 

accessible to my entreaties that he come to Heidelberg. He came to 
us to our very great joy in the autumn of 1902 and our hopes revived 
that we might reap rich fruits from the work together of the two 
friends who were now free from all pressing responsibilities. 

My call to leave Heidelberg in the fall of 1903 put an end to this 
hope before Alzheimer had yet been able to be received. He now 
went with me to Munich, where I thought I could create a larger 
working circle for both investigators. Nissl, however, was soon 
called to the chair at Heidelberg, so that to Alzheimer alone fell the 
task of putting in order the beautiful anatomical laboratories of the 
Munich clinic and filling them with life. It remains in the memory 
of us all with what devotion and with what brilliant results he per- 
formed the task. Here at last his scientific personality could develop 
freely. It can be readily understood, therefore, that within a short 
time the laboratories were filled with more or less able students from 
all leading countries 2nd that a long series of valuable works was 
produced under his unwearied direction and inspiration. In spite of 
this wide activity in teaching he still found time to promote vigor- 
ously his own fundamental researches to bring to a conclusion his 
great work upon paresis, and besides many individual researches, 
gradually to bring together the material for a comprehensive pre- 
sentation of the pathological anatomy of the mental disturbances. 
Besides this he was especially occupied with a study of the de- 
composition processes in the cortical tissue, also the important ques- 
tion of the anatomical groundwork in idiocy, particularly the re- 
tardation in development. For this work he had brought together 
a rich collection of brains. 

His new position, of course, was not entirely free from hindrances. 
In the first place, the clinic afforded only very modest material com- 
pared to the greatness of the tasks which Alzheimer had set him- 
self. It throws a bright light upon the personality of this dis- 
tinguished man that he made the greatest sacrifices with a serene 
independence in order to pursue his scientific ends. Not only did he 
renounce every reward for his work but he defrayed also the far 
greater part of the expenses of the carrying on of the work from 
his own means, the preparation of drawings and photographs, the 
fees for technical apparatus, for the objects which came to him from 
the most varied sources. In spite of all this, he never thought of 
limiting his activity in the carrying forward of the anatomical work. 
He gave me his most unselfish support, with the unshakable loyalty 
and trustworthiness which distinguished him, in the difficult early 
organization of the clinic and, later, also in the allaying of the friction 



94 EMIL KRAEPELIN 

that would arise here and there within the work and in the watch- 
fulness which he maintained over the medical service. The implicit 
confidence which was manifested to him from all sides and his quiet 
objective manner were of the greatest help in smoothing out affairs 
and setting aside difficulties so that imperceptibly he came to be the 
sure support of the activities of the entire clinic. He became quite 
indispensable after Gaupp was called elsewhere and so in time he 
was prevailed upon to take over also the office of head physician. 
He suffered so, however, under this burden that I had to yield to his 
importunity to as soon as possible to remove it from him. 

Alzheimer threw his whole soul into his work and could not be 
diverted from it. Without doubt his health suffered from this. He 
succeeded in wresting time for a short walk through the streets in 
the late evening hours at my pressing remonstrance, otherwise he 
scarcely knew any recreation. It was as good as impossible to move 
him to a longer holiday; after a short period he returned because 
this or that work must not be retarded. He always found excuses 
to crowd out relaxation. Not until his last years did he secure him- 
self a country home, which afforded him the welcome opportunity 
to work in the garden and to pursue his botanical tastes. I was also 
able to entice him occasionally to a mountain trip. This was difficult 
for him because he thought he had no time for bodily exercise. 

In 191 2 he was called to Breslau. This was a great gratification 
to him, because in spite of the consciousness of his inner worth he 
suffered from the fact that his position did not truly correspond to 
what he stood for. I was sorry to see him depart. Much as I re- 
joiced at the deserved recognition which lay for Alzheimer in his 
call, yet I was assured that the high point of his scientific attainments 
was passed. I pointed out to him at his departure, that some day he 
would look upon the time spent in Munich as the happiest of his 
life. I do not know whether the latter came to pass, but that the 
former was correct has alas shown itself all too soon. 

On his removal to Breslau, Alzheimer beer me ill with a severe 
infection which involved his kidneys and affected his heart, which 
already was weakened in resistance. He gradually recovered and 
began to take up now with his customary devotion to duty the mani- 
fold and heavy burdens of his new position. Alzheimer did not 
understand how coolly to thrust away pressing demands when he 
considered them justified. In 1909 the plan for a new psychiatrical 
journal came up and I had to put the question to him whether he 
might perhaps be ready to take upon himself a share in its direction. 
I was surprised by his immediate acquiescence. When the affair 



THE LOSS OF THREE GERMAN INVESTIGATORS 95 

seemed a necessary one he did not hesitate, to put at its disposal a 
considerable share of his working time, otherwise arranged with 
such care and to such advantage. 

Thus in his illness he had no mercy upon himself, although he was 
suffering severely, as for example when the conditions of the war 
forced him to an ever greater strain upon his already failing 
strength. He sacrificed his health without consideration up to the 
last of his powers until on the 19th of December, 191 5, at the age 
of 51, this man who seemed of such unusual vigor, succumbed to 
this insidious disease, a few years after he had attained the goal of 
his wishes. The great comprehensive work upon the pathological 
anatomy of the mental diseases, which should have crowned his life 
work, was not to be accomplished. The preliminary work was so 
far advanced when Alzheimer left Munich that we believed our- 
selves justified in expecting the speedy conclusion. Only a few 
items were found after his death in regard to the final completed 
work. Everything else was lost with him. 

A few years later we had to mourn the unexpected and premature 
death of Brodmann. His life also was an unbroken chain of the 
most energetic labors. These began, after a period of preparation 
in medical practice and service as physician in mental disease, with 
his inspiration to brain anatomy first through Oskar Vogt and then 
in the year 1900 with Alzheimer in Frankfurt. There followed ten 
years of hard work at the Neurobiological Institute under Oskar 
Vogt, where he worked with abundant material. Here he was 
occupied chiefly with research into the cellular structure of the brain 
cortex. Now he could give his entire strength to his great life task. 
Though this did not exclude his devoting himself also to some indi- 
vidual researches in the field of experimental psychology. He there- 
fore obtained a mastery in the delimiting of the individual cortical 
fields which enabled him to pursue the path of the solution of that 
most difficult question, the relationship between the structural plan 
of the brain tissue and psychic functions. 

It is easy to understand that a man of the self forgetful spirit of 
Brodmann would be possessed little by little of the idea to seek to 
try his powers in academic pathways. This path was closed to him 
in Berlin, so in 191 1 at the age of 43 he moved to Tiibingen, where 
with Gaupp's support he attained his goal. Unfortunately the Tiib- 
ingen clinic, too, could offer him but a very modest position. There 
very naturally fell to him there a share of the medical service so 
that he could devote only half his strength to the scientific work for 
which he was so exceptionally capable and so well equipped. Nissl, 



96 EMIL KRAEPELIN 

it is true, furnished him wi'.h a certain sum, through the Heidelberg 
Academy, which enabled him to carry forward his costly researches, 
but it could not be hidden from himself as well as his friends that 
the duties of his position seriously hindered him in the pursuit of his 
broadly prescribed goal. His distressing domestic situation also, 
which cut off every prospect of attaining complete independence and 
of establishing a family, oppressed him at the same time that he had 
to recognize that in spite of his self sacrificing industry and his im- 
portant achievements he must remain behind many of his fellow 
workers, who without any effort had availed themselves of com- 
fortable positions in life. 

The cail in 1916 to the office of assistant professor of anatomy at 
the institution in Nietleben, came to him as a salvation. Now at last, 
almost 48 years old, he succeeded to fairly satisfactory domestic 
conditions, which permitted him to marry. At the same time he was 
released from the duties of medical practice and might give himself 
entirely to his research work, which began to assume more and more 
fruitful prospects through the bringing together comparatively of 
anatomical viewpoints, and investigations. He welcomed this change 
in his fortune with touching gratitude. 

It was such feelings that made his decision difficult for him when 
two years later the call came to him to the German Institute of Re- 
search. It seemed to him like deserting the colors to leave so soon 
again the position which had created for him such kindly relation- 
ships. Only the quieting reassurances of all concerned were able to 
dispel these thoughts. So at the beginning of April, 1918, he entered 
Munich with a joyous heart to find here a field of activity which 
afforded him in still greater measure complete freedom for research 
together with abundant material. Within a few days he had ar- 
ranged his laboratory and set up his collections of material. He 
went to his work with youthful enthusiasm undertaking the prepa- 
ration of far-reaching researches, which should turn to account his 
rich knowledge and ability in psychiatry. 

It was perfectly evident from the first that Brodmann's services 
must be obtained for the German Research Institute. The results 
of his efforts lay first more in the territory of comparative anatomy, 
individual and racial anatomy of the cortex. Still these showed the 
direction in which pathological anatomy of insanity must later be 
developed. When it has been accomplished that the changes pro- 
duced through a definite disease process are pointed out trustworth- 
ily and from all sides, then the extension of these into the brain can 
be established, the number and kind of cortical territories invaded. 
There is no way to this goal except through the cyto — and myelo- 



THE LOSS OF THREE GERMAN INVESTIGATORS 97 

architectonic study of the cortical structure instigated by Vogt and 
Brodmann. Brodmann's work, together with Nissl and Spielmeyer, 
seemed, therefore, the most important advance in knowledge of the 
way in which the different disease processes have spread and it 
seems to promise the opening up of revelations in regard to the con- 
nection between cortical changes and disease phenomena. The re- 
lations of these investigators, who for a long time had stood close 
in thought and feeling, were already in these first months of daily 
intercourse exceptionally satisfactory, so that we confidently looked 
forward to the further development of this cooperation. 

So much the more terribly the blow struck us which suddenly 
shattered all our hopes. Brodmann died on the 22d of August, 1918, 
just 50 years old, a few months after he had attained his lifelong 
wish to be able to devote himself freely to his science. His death 
was the result of a severe sepsis associated with influenza, which 
apparently was combined with a toxic infection contracted at an 
autopsy the year before. The wealth of material in experience and 
scientific hypothesis, of which up till this time Brodmann had not 
been able to avail himself, was thus lost forever. There was no one 
who could take his place. It is very uncertain whether or when 
another will be found who will tread the toilsome paths which Brod- 
mann followed with the same ability and perseverance. What he 
had accomplished is of course not lost, but incomparably more could 
he have given us if it had been permitted him to wish for one or 
two decades more, devoting his full powers to his great work to 
which his life had been consecrated. 

One year later Nissl left us. He had succeeded in his student 
days in discovering that staining method which made possible the 
knowledge of the finer structure of the nerve cells and their patho- 
logic changes. Gudden recognized at that time the exceptional gifts 
of the young physician and brought him into close relationship with 
himself. There in the institutional circle at Munich, Nissl found 
time with his exhausting institutional service to become familiar 
with the fundamentals of Gudden's degeneration methods, to sup- 
port his theory by endless hard work and at last to go his own ways, 
by which he strove to understand the physical basis of insanity. We 
find him again, a few years after Gudden's tragic death, as head 
physician in Frankfurt. Here he found an enthusiastic fellow 
worker in Alzheimer. The extensive and responsible management 
of the asylum at Frankfurt, which he undertook making at the same 
time thoroughgoing changes, made the greatest demands upon the 
powers of the small staff of physicians. It seems almost incredible 



98 EM1L KRAEPEL1N 

under these circumstances what an enormous amount of research 
work was carried out at this time by the two friends. This was 
possible only because literally the greater part of the night after the 
strenuous service of the day was devoted to science, a custom from 
which Nissl later found great difficulty in breaking off when his 
position in Heidelberg permitted him greater freedom of movement. 
There is no doubt, however much we may admire Nissl's self forget- 
ful devotion to his life work, that this persistent disregard of his 
physical needs left its traces upon him. 

Nissl left Frankfurt for Heidelberg in 1895. He gave up his 
assured position for greater freedom in academic circles for his 
scientific work. We could offer him at that time only the most 
modest living conditions and I could not at once release Nissl en- 
tirely from medical service, to which he, however, willingly sur- 
rendered himself. He felt himself, however, essentially liberated and 
carried out at once his marvelous researches upon the influence of 
" the subacute maximal intoxication " upon the nerve cells. He also 
completed his book on the neuron theory and devoted himself with 
greatest zeal to the study of pathological cortical pictures, particu- 
larly in paralysis and lues of the brain, and further to the employ- 
ment of the revelation of conditions through lumbar puncture. He 
was supported in these branches of the work by a series of pupils 
who little by little sought instruction in the small clinical labora- 
tories. 

My call to Munich and Bonhoffer's removal to Breslau soon after 
resulted in Nissl's appointment in 1904, as professor in ordinary of 
psychiatry in Heidelberg. My plan to take him with me to Munich 
was thus shattered. I must acknowledge it would have been doubt- 
ful if I could have realized it satisfactorily at that time. The new 
position burdened Nissl with many duties, the fulfillment of which 
fell upon him with especial weight because of his conscientiousness 
and carefulness. The conducting of the clinic, the medical service, 
the instruction, the examinations and meetings, as well as the un- 
avoidable practise absorbed his time and strength out of all pro- 
portion, so that here again only scanty leisure hours were left for 
scientific work. He succeeded, however, in the course of the year in 
spite of all hindrances in completing his pioneer researches in regard 
to the' condition of the brain cortex detached from its connections 
and in taking up the investigation of the relationship of dependence 
between the different cortical areas and the thalamic nuclei. Natur- 
ally all these important tasks proceeded slowly in constant conflict 
with the excess of duties. 



THE LOSS OF THREE GERMAN INVESTIGATORS 99 

A further undertaking, by which Nissl sought to approach his 
final goal, the anatomical study of disease processes, was the bring- 
ing together of individual cases studied carefully, clinically and 
anatomically, which he had begun. These thus gradually created was 
to be a material for observation corresponding to all scientific de- 
mands, which should permit the discovery of sure relationship be- 
tween clinical pictures and definite cortical changes. The very first 
observations, here presented, showed how valuable for the further- 
ing of our science this form of study could become in Nissl's hand. 

Any one who knew Nissl well could not fail to notice that a 
change gradually took place in him in the course of the last ten 
years. The powerful ardor of his nature seemed dampened ; he had 
grown less robust and could not longer push his work forward with 
his earlier disregard of self. An insidious kidney disease, which he 
tried to combat by a winter in Egypt, warned him to have some re- 
gard for his strength. His health was in danger and the possibility 
had to be considered that his knowledge and ability, which could not 
be replaced, the entire wealth of his scientific schemes and thoughts 
might some day be irrecoverably lost. It seemed therefore as a 
most pressing concern of the German Institute for Psychiatric Re- 
search, to arrange for a worker like Nissl freedom from the burden 
of office and so unhindered freedom for productive activity as long 
as his health still permitted this. 

Nissl without long delay seized the opportunity given him in spite 
of the no small sacrifice which the giving up of his position laid 
upon him. In April, 1918, he came to Munich and entered at once 
upon a busy activity partly in a lively exchange of views with Spiel- 
meyer and Brodmann, partly in preparation of a larger work upon 
his researches in the optic thalamus. He smilingly repulsed the often 
repeated suggestion that he should now and then permit himself 
some recreation with the remark, that now all his days were holi- 
days. All sorts of plans stirred him, which he wanted to take hold 
of after he had completed his work on the thalamus. These were 
the study of the brain changes in dementia praecox and further the 
experimental proofs of the attempt to delimit the cortical areas on 
the ground of the anatomical structure. Here his work would have 
joined that of Brodmann. 

Fate decreed otherwise. On the nth of August, 1919, Nissl suc- 
cumbed to his old disease before he had brought to conclusion even 
his work on the thalamic nuclei. Our loss in him cannot be meas- 
ured. It is not alone that Nissl possessed an enormous treasure of 
knowledge and experience as a result of his unwearied industry, 



ioo EMIL KRAEPELIN 

which gave him in his field an exceptional sureness of judgment. 
He possessed also a severity of self criticism which kept him almost 
entirely from mistakes and hasty conclusions. It was his superiority 
over all his fellow workers striving in the same direction and lent a 
decisive weight to the opinions he expressed. Nissl was besides a 
master of technic and his was a head uncommonly full of ideas, 
although he never permitted his secret hopes and expectations to 
influence his rational appraisal of actual facts. Thus all the gifts 
which distinguish a student of natural science were united in him; 
he was born to this calling. 

This survey of the here briefly indicated fate of these three dis- 
tinguished men, whose loss we have to mourn, brings this affecting 
fact forcibly to us, that our science has only remotely obtained that 
result from their powers which could have been reached under more 
favorable conditions. And no matter how rich their life work has 
been, it was yet most seriously impaired through the circumstance 
that they were grievously hindered in the free exercise of their 
peculiar gifts. This was because for many years or decades at the 
height of their ability to accomplish great things they were burdened 
with other affairs. The path assigned to the mental physician is such 
that his professional service demands his best powers and the scien- 
tific work can be undertaken at the best only as a side issue and 
with the sacrifice of the hours of recreation. Entrance into the 
academic circle makes little difference. Whoever considers becom- 
ing - a professor of psychiatry in Germany has in every case no time 
to enter more deeply into auxiliary sciences. His work at the sick 
bed must remain his chief concern. If, however, he has attained his 
goal, yet beside this instruction, examinations, administration and 
always practise as well, put such high demands upon him that the 
possibility of creative scientific work more and more fades away. 

Our three investigators were able only under the greatest per- 
sonal sacrifices to traverse those paths into which their talents 
forced them. The best that they had to give us they could wrest for 
themselves only in continuous struggle with the conditions which 
demanded from them quite different achievements, those which did 
not accord with their peculiar gifts. It was a waste of valuable 
working force that Alzheimer and Nissl had to earn their bread for 
long, long years as physicians in asylums, yes, even that they became 
professors of psychiatry because in this way their gifts in largest 
part were made fallow. The same might be said of the fact that 
Rrodmann was compelled to devote a great part of his time in a 



THE LOSS OF THREE GERMAN INVESTIGATORS 101 

poorly paid position to the discharge of duties which many others 
could have attended to as well or even better. 

The way we should enter upon to avoid such loss is clearly 
marked out. It should no longer be left to the rare talent for re- 
search which grants us its kindly skill, to seek in some way or other 
for itself opportunity for activity with unspeakable trouble and con- 
flict but we must create the conditions for it under which it can grow 
and fully unfold its powers. The only way to do this is by the 
establishment of life positions which guarantee freedom and suf- 
ficient aid for scientific work. It goes without saying that not every 
clinic or insane asylum can offer satisfactory conditions to an entire 
staff of research workers. The suitable persons for placing in such 
positions would very soon be wanting also. The large schools and 
communities might well strive, however, to procure little by little, 
here and there for an exceptional investigator proper means for ex- 
istence and for work. In this way a division of work would be well 
brought about in such fashion that in our place this, in another that 
aid to psychiatry would be especially provided. We can see the be- 
ginning of such a development in the position of anatomist founded 
by Pfeiffer for Nietleben and also in the model arrangements of the 
Hamburg institute, where beside an anatomist a serologist is also 
working. Similrr positions can be found elsewhere only mostly far 
too poorly equipped. 

The richest result naturally is promised always by the association 
of a line of distinguished scientific personalities in one institute for 
research. It is just the daily close intercourse and the mutual work- 
ing over of the same questions from different points of view which 
will first make possible the highest use of the forces at hand. It was 
unfortunate that Brodmann and Nissl succeeded in obtaining such 
favorable conditions only shortly before their end. It is clear to 
any one with any penetration what advantage it would have been for 
our specialty if both workers had been put into the position ten or 
fifteen years earlier in complete freedom to have devoted their full 
power to reaching their high goal. We should all be united in st>iv' 
ing to be careful that hereafter no truly exceptional talents in our 
field need be allowed to waste themselves in the duties of the day. 
but as soon as they have proved themselves to exist, should find a 
place which would afford them the highest use of their powers. 

The unfortunate outcome of the World War has most seriously 
interfered with the development of such plans. Our people have 
become poor and in no condition to make further sacrifices. We 
must take into consideration that the German Research Institute 



icc EMIL KRAEPELIN 

also is hindered in its development and cannot fulfill the fair hopes 
which we entertained when it was founded. It is plain in the mean- 
time that we must not at any price lose the impetus in scientific work 
which German intellect and German industry has won. Here lies 
still one of the strongest sources of our power. In psychiatry, too, the 
founding of the first institute for research amid the storms of the 
World War can assure us that Germany will be able to preserve the 
place, which she had won for herself in the scientific world. It will, 
of course, be necessary that the work of all those in our profession 
be brought together. Such an institution can flourish only when it 
is upheld by the inner participation and the practical support of the 
widest circle. May the fate of the three workers who have gone 
from us be thus a reminder to every German mental physician to 
work toward this end through his own fellowship in work and 
through zealous research. Thus the .first great attempt to open 
up free paths for psychiatric research may be saved for a better 
future as a worthy testimonial to German science out of the sorest 
period in the history of Germany. 






Society Proceedings 



NEW YORK NEUROLOGICAL SOCIETY. 

The Three Hundred and Ninety-second Regular Meeting 

was Held at the New York Academy of Medicine on 

Tuesday, December 6th, 1921, at 8:30 P. M. 

Dr. Foster Kennedy of New York, in the Chair. 

Syndrome of the Retroparotid Space with Special Reference 
to a New Interpretation of some forms of Facial Paralysis (Pre- 
sentation of a Case). Dr. Byron Stookey. 

[Authors's Abstract]. 

Dr. Stookey presented a patient showing a pure syndrome of 
the retroparotid space as described by Villaret (1916). Though 
the injury was sixteen years ago, complete paralysis of the glos- 
sopharyngeal, vagus, spinal accessory, hypoglossal and cervical 
sympathetic nerves still remained with ptosis of the eyelid on the 
same side, miosis, narrowing of the palpebral fissure, enophthal- 
mos, loss of taste dorsal third of tongue with difficulty in swal- 
lowing and eating, paralysis and atrophy of the tongue and 
weakness in elevation of the arm due to paralysis of the trape- 
zius. Attention was called to the development of the clavicular 
portion of the pectoralis major and the clavicular head of the 
deltoid, both of which stood out prominently on elevation of the 
arm beyond one hundred and fifteen degrees. These two mus- 
cles thus compensate for the loss of rotation of the scapula in 
elevation of the arm. 

Oblique withdrawal of the dorsal wall of the pharynx toward 
the sound side — movement de rideau of Vernet — was demon- 
strated, but Dr. Stookey did not feel that in this patient this 
sign could be taken as a sign of glossopharyngeal paralysis in 
view of the other nerves involved. Vernet's view that the vagus 
is a purely sensory nerve was denied in view of the histological 
character of the dorsal motor nucleus of the vagus and the 
nucleus ambiguus as shown by finer histological studies of the 
nuclei of the vagus following section of the vagus. Its efferent 
character, as well as efferent, was emphasized. In Dr. Stookev's 
patient a slight facial weakness at rest was noted, though the 
facial nerve was intact and there was no weakness in voluntary 
movements. There seemed to be rather a loss of tone. In view 
of the fact that striate musculature possess a dual efferent inner- 
vation, this loss of tone, it was felt, might be due to loss of the 

103 



104 NEW YORK NEUROLOGICAL SOCIETY 

efferent sympathetic fibers to the facial musculature because of 
injury to the superior cervial sympathetic ganglion. 

Discussion: Dr. Smith Ely Jelliffe sdd he was delighted to 
hear Dr. Stookey bring forward one of the points he had tried 
to raise at the last meeting, in the discussion of myasthenia 
gravis, namely, the sympathetic innervation of the musculature 
in the myasthenic reaction. He said he thought that Dr. 
Stookey has been a little over careful in advancing his hypothe- 
sis of double innervation, and that he has stuck rather too closely 
to the anatomical evidence alone. It has been known for many 
years that the richness of emotional expression is greater in the 
facial musculature than in that of any other part of the body. 
It seems that the splanchnic remnants are over-represented in 
the facial group. 

Dr. I. Abrahamson said he thought the dual innervation might 
account for the frequency of contractures after facial palsy. This 
occurs more often than with any other cranial nerves. While 
explanations of contractures have been many and varied, none 
of them seem to fully account for the phenomena. A second 
corollary is the occurrence of the facial hypotonia seen in tabes, 
causing sagging of the features. It is known that the cervical 
sympathetic is often attacked in tabes. Facial contracture can 
be regarded as a tonic spasm, on account of the loss of normal 
equilibrium between the clonic and the tonic parts of the mus- 
culature. 

Dr. Foster Kennedy said that he was surprised that Dr. 
Stookey laid such emphasis on the comparatively recent recog- 
nition of the syndrome as an entity, which surely preceded the 
date that Dr. Stookey gave. Was not this condition diagnosed 
by many of the members as early as 191 5? He recalled a case 
in the Neurological Institute in 1910, in which luetic involvement 
of the skull gave evidence of a lesion clearly recognizable as that 
described by Dr. Stookey. In the war, too, cases were noted 
with frequency. The sign of glosso-pharyngeal paralysis by 
deviation of the uvula has been recognized since 1907. He hoped 
it was not an impropriety to refer Dr. Stookey to a paper by 
Maloney and Kennedy, in 1912, on pressure signs in the face. 

Dr. Byron Stookey, in closing, said he would add nothing to 
the evidence in regard to the spheno-palatine. It is supposed 
that the supply of the parotid through the ninth nerve is from the 
nucleus salkarius to the otic ganglion and thence by the auriculo- 
temporal nerve. The preganglionic fibres are from the ninth 
nerve, and the postganglionic fibres from the otic ganglion 
through the auriculo-temporal to the parotid. 

In answer to Dr. Kennedy, there is no reference earlier than 
Villaret in 1916, to the retro-parotid space as a locus of extra- 
cranial injury of those nerves. The syndrome of Hughlings- 
Jackson is not extra-cranial. Tapia and Schmidt refer to lesions 
involving the nucleus ambiguus, but these are intra-, no extra- 
cranial injuries. Did Dr. Kennedy's case involve the cervical 



NEW YORK NEUROLOGICAL SOCIETY 105 

sympathetics? Dr. Kennedy has referred to deviation of the 
uvula, but this is, of course, totally different to deviation of the 
posterior wall of the pharynx due to paralysis of the superior 
constrictor muscle. In paralysis of this muscle the pharynx is 
drawn obliquely over to the sound side — " mouvement de 
rideau." Does not the President's reference to his own work 
deal exclusively with the afferent innervation of the face, and 
not the efferent? If Dr. Kennedy's work referred to a dual 
innervation it antedated all other work in this line by quite a 
few years. 

Dr. Kennedy said his work does not conclusively show this 
point, but it was an adumbration of the study of the pressure 
signs of the face. 

Dr. Stookey said he was pleased to know that Dr. Kennedy's 
work dealt solely with the afferent side, as he wished to empha- 
size that his paper this evening referred to a dual efferent inner- 
vation, not afferent. 

A Psychiatric Study of Suicide. 

Dr. Thomas W. Salmon read this paper. He said he desired 
to present the human, rather than the professional side of the 
problem. It is stated that there are few people who at some 
time or other of their lives have not thought of self-destruction, 
but it is not easy to see exactly what is meant by that statement. 
It is true that most people, in childhood, have visionecl being 
laid out in the best chamber, surrounded by weeping relatives 
and members of the family, who are overcome with grief at their 
former unappreciation of the departed. Thoughts of suicide are 
almost equally wide-spread, and most people who have left auto- 
biographies have spoken very definitely of suicide, but these 
thoughts are usually disposed of by the mechanism which we 
possess to dispose of ideas which interfere with our happiness, 
and the relative infrequencv of suicide accomplished, as com- 
pared with thoughts of self-destruction, bears witness to our 
power of preventing this type of casualtv. 

Apart from the human standpoint, suicide is of interest as a 
psychiatric study : first, because it is clue to a preventable phase 
of mental disorder; and, second, because it involves questions of 
therapeutics and of hospital management. Recently suicide has 
taken on a new and wider interest, and it is from this larger 
viewpoint of methods rather than material that we have under- 
taken this study. Not only were cases considered which were 
allied to frank mentrl disorder, but also those in which this 
strange disturbance of human conduct occurred in sane persons. 
Dr. Stearns took as an associate in this study a well-trained 
social worker, and tried to follow up every single case. A period 
of six months was taken for intensive studv. The studies pre- 
sented many difficulties, because it was not always possible to pre- 
cede the undertaker or to follow the police, or to be welcome in 
every home, but every available channel of evidence was used. 



106 NEW YORK NEUROLOGICAL SOCIETY 

The successful collection of minute details for study was due 
to splendid cooperation on the part of those interested in the 
study, such, for instance, as medical examiners. After these 
people, it was found that the gas companies were those next 
interested, whether on account of the amount of gas wasted or 
not, is not clear. 

Generally speaking, it would seem to be a simple matter to 
determine whether or not suicide took place, but those_who have 
studied the subject tell us that probably not more than two- 
thirds of suicides are reported, and that many cases are mis- 
takenly termed suicide ; also many cases are associated with 
homicide, so that a double toll of lives has to be estimated. Any 
personal stress or economic stress may be associated with sui- 
cide, but no one knows the exact proportion of these cases. 

Sentiment which interferes with these investigations may be 
of two kinds : in some cases the relatives want the suicide made 
widely known ; this usually has to do with various religious pro- 
cedures which are modified in case of suicide : on the other hand, 
every effort is made to assign the death to natural causes instead 
of to suicide. For this reason one sometimes gets better evi- 
dence from neighbors than from relatives. Dr. Stearns found a 
typical illustration of this in one case of a very old man who 
suicided. The relatives were reticent but a carpenter, who lived 
next door, told the doctors that he knew the old man would com- 
mit suicide, because he sat for hours in the carpenter's yard 
without speaking, and when he spoke it was to complain that 
his bowels ended in the middle, and that a man in that condition 
ought to be dead. The physician who attended the family con- 
firmed this evidence. 

Suicide from suggestion is not uncommon. One very old man 
travelled all the way from Chicago to hang himself in a certain 
barn, because it was the custom for members of his family to 
do so, and he wanted to commit suicide in the orthodox way. 
The obvious cure in a case of this kind would be to burn down 
the barn and prevent further incidents. In New Orleans there 
is a " suicide oak " which no doubt has helped, with the aid of 
suggestibility, to put many persons out of the world. 

The statistical study of suicide shows that it is steadily on the 
increase in all American cities. Many theories have been 
advanced, but the one most feasible is the fact of the steady drift 
of the population to the cities. Whv suicide should be more 
common in cities needs careful analysis. Perhaps availabilitv of 
weapons has something to do with it, as also the ready supply 
of gas. Dr. Stearns found a very striking relation between 
depression and suicide, and also that the suicide rate rises with 
every decade of life in a uniform manner. In the eighth and 
ninth decades it is remarkably high. He found a high racial 
rate among the Irish, in contrast to the low rate found by other 
workers. Among the foreign born the rate is higher. This 
reflects the greater economic stress in this section of the com- 
munity. 



NEW YORK NEUROLOGICAL SOCIETY 107 

Factors of medical interest are those of relation of suicide and 
mental disease ; 42 per cent of cases give a history of mental dis- 
order, and if we include psycho-neurotic cases this rises as high 
as 58 per cent. Where mental disorder is present 70 per cent 
of all suicides occur in the manic depressive groups; 23 per cent 
have other psychoses making a total of 93 per cent of mental 
disorders in which depression is a marked factor. Contrary to 
the usual idea, there are often depressive cases and suicides 
among psycho-neurotics. If it were not for the fact that most 
mental cases are hospitalized and guarded, the number of sui- 
cides in this group would be alarming. In a group of this kind 
studied, 157 in number, 7 were among children. Child suicide, 
has been made a study by itself, but Dr. Stearns secured full 
data in these cases, and it was surprising what abnormality 
existed long before suicide occurred. 

This wealth of descriptive material points to definite measures 
of prevention. The figures for the suicide death rate are higher 
than that for typhoid fever. We spend large appropriations on 
prevention of typhoid, but we do nothing to prevent suicide. 
The very first preventive measure of importance that occurs to 
one is the importance of recognizing depressions in their earliest 
stages. This is a responsibility for the public and for the medi-'' 
cal profession. A distinguished surgeon in Chicago told me 
that a minister of his acquaintance was fond of coming into his 
office, and that the man wasted the doctor's time by telling him 
how worthless he felt himself to be, and what a discredit to his 
profession. The surgeon said to him: "If I felt like that, I 
would go to the lake and walk east till my hat floated." Finally, 
this is exactly what the minister did. The suggestion was the 
final link between depression and suicide. The danger is great- 
est in the early and the late stages of manic depression. In the 
severe stages the mind does not focus clearly on the suicidal 
idea. 

In one case recalled, that of a magazine writer, the man came 
into my office and introduced the topic of what became of 
unclaimed bodies found in the East River. He said he had a 
professional interest in the problem. The man had a pallid, 
unhealthy appearance and it was suspected that he was suffer- 
ing from depression. I told him that the bodies were distributed 
to the various dissecting rooms for the use of medical students. 
Feeling that confession might pave the way to relief, I went on 
to speak franklv of the subject of suicide in eeneral and to sketch 
an outine of the questioner's probable mental symptoms. This 
produced a response on his part, and he admitted to me that he 
was suffering from acute mental deoression. I hold him that his 
symptoms were extremely susceptible to treatment and urged 
him to go to a hospital to be taken care of. Arrangements were 
at once made for his reception at Bloomingdale and that same 
evening he was under hospital care. He expressed himself as 
well satisfied, and stated that he felt very much safer when he 



108 NEW YORK NEUROLOGICAL SOCIETY 

saw the nurse patrolling the corridors at night and he was able 
to rest comfortably. Unfortunately, his brother came on from 
Chicago and was very indignant that the patient had been placed 
in an institution by a " fool doctor." He took his brother out 
with the idea of taking him home. It was stated that on the 
journey home the patient appeared unusually light-hearted and 
facetious. He was sure that the patient was much better. On 
arrival the patient made an excuse to go to the bathroom for a 
few minutes, and when there he cut his throat. This case illus- 
trates the absolute necessity for care in the early depressive 
stages and indicates clearly the need for early treatment. 

During the war statistics showed that war must have been in 
some measure a substitute for suicide. The A. E. F. figures 
were 5 per 100,000, in contrast to the regular army figures of 53 
per 100,000. This large difference probably needs many causes 
to explain. One factor may be the exclusion of those obviously 
suffering from mental disorders. Hospitals were available from 
the front line to the base for early mental symptoms, and the 
slightest abnormality was reported early. Probably the treat- 
ment was better in the Argonne than in New York City to-day. 

We have very powerful resources in our prevention of suicide. 
Many patients who attempt suicide give positive evidence of a 
long period of conflict before the act. between the desire to die 
and the instinct to live. The Rev. Dr. Warren has instituted 
what he calls the Save-a-Life League. He answers telephone 
calls from people about to commit suicide. He has some one on 
hand day and ni^ht, and by entering the field from a different 
angle, that of religious and moral counsel he saves people at a 
critical time. He has a wonderful collection of letters and his- 
tories testifying to the results obtained. Probablv the most 
powerful aid is the factor of human friendliness, which is so often 
lacking in our medical treatment of these cases. One is struck 
by the extreme loneliness and isolation of the sufferers seen at 
Bellevue hospital, after being rescued from attempted suicide. 
A powerful human resource has not been put into use. In Japan 
there exists an anti-suicide league, and on the railway crossings 
it is suggested that these should not be used for suicidal pur- 
poses. Whether the suggestion works- in the direct or the 
reverse fashion is doubtful. 

The suicidal intent often lasts for years and years before con- 
summation. In Wisconsin, in rn insane asylum, a man built an 
extraordinary barn, with fantastic cupolas. He kept adding one 
after another, and when he was unable to add another, he hanged 
himself on the last one. The constructive work had probably 
been a sort of safeguard, and when this was exhausted, he sui- 
cided. Had the architectural standards of Wisconsin allowed of 
an indefinite number of cupolas, he might have lived to old age. 
In another case the safeguard proved to be an altruistic reason. 
An insane man, while walking with a new attendant tried to 
jump into the river. The attendant cried out anxiously, " Don't 



NEW YORK NEUROLOGICAL SOCIETY 109 

do that or I shall lose my job." This plea deterred the suicide 
at the moment of impulse. 

In regard to other preventive measures, Dr. Stearns suggests 
that something might be done to lessen the extreme suggesti- 
bility of the intending suicide. While the world cannot be 
adjusted to the psychopathic mind, one can place some restric- 
tions as to suggestion on the movies and the drama. Firearms and 
gas can be safeguarded. The fact that there is a diminution of sui- 
cide by drowning in winter, on account of the freezing water, shows 
that availability has something to do with it. The policy of avoid- 
ing frank discussion with the patient seems to be a poor one. 
Often confession proves helpful. The details of general statis- 
tics tell little, and the method for future study is the carefully 
worked out case method, from histories of patients who have 
been rescued. The time for prevention is during the early and 
late stages of depression, when there is a conflict between the desire 
for life and the choice of death. 

Discussion: Dr. Smith Ely Jelliffe said that the subject was 
so large that many points have, necessarily, to be left untouched. 
The metaphor of the barn, used by Dr. Salmon, could be taken 
as an illustration of a type of reconstruction process which takes 
place in the mind of many neurotic patients. The construction 
of psychologcal barns can be seen as a protective mechanism. 
If this fact is not recognized, the patient may, in the end, get 
beyond protective mechanisms. Another important point is the 
recognition of the fact that what may appear as a psychoneu- 
rosis on the surface mav be the early stage of a severe mental 
disturbance. The psychiatrist must endeavor to change the 
mode of expression of the patient into something beneficial. Delu- 
sions represent ego-protective devices, and they may be piled up 
more and more, one above the other. At times these delusional 
formations of pronounced grade may be replaced by religious, by 
mystic or by other expression of a less outre type. The early 
and late stages in manic-depressive patients are particularly dan- 
gerous ; in the early stages they are suicidal, not having built up 
their delusional defense mechanisms; in the latter the patient 
has come through a rich delusional stage and has to be pro- 
tected until he gets back to his average. In regard to methods, 
the analytical method is often much condemned because so fre- 
quently misunderstood, but it mav be helpful at a certain stage 
and more often saves the patient from the river than drives him 
to it, as some superficial and non-psychiatrically trained physi- 
cians often claim. To frighten patients away from a competent 
psvchiatrist is as criminal as it is to allow non-technically 
trained neoole to treat mental illnesses. 

Dr. S. R. Lerhy said that while dementia precox is not usually 
thoueht to be associated with suicide, this is not an infrequent 
combination. When one considers the type of hallucinations, 
it is surprising that more suicides do not occur. The patient 
may endeavor by suicide to escape the imagined dangers threat- 



no NEW YORK NEUROLOGICAL SOCIETY 

ening him. The dementia precox suicides are impulsive in type. 
They do not speak of the intention, and evade the issue. If once 
prevented, they become more determined to suicide. In indi- 
viduals with marked mental and motor retardation suicide is 
unlikely. They cannot plan self-destruction. The fact that 
families do not want to put depressed patients in hospitals often 
leads to suicidal attempts. They are not properly guarded. 
Patients with alcoholic hallucinations are apt to commit suicide 
on impulse, to escape their terrors. They are likely to jump off 
ferry boats or to do similar acts. Any condition, organic or 
functional, producing depression, makes suicide likely. This is 
seen in arterio-sclerosis or general paresis. 

Major Jarvis (by invitation) said that the profuse advertising 
of every suicide case, with its appeal to suggestion, is to be 
deplored. Considering environment in rural districts as a factor, 
Bismarck drew settlers from remote districts for his rural com- 
munities, because of the large percentage of suicide. Environ- 
ment is an important factor, as evidenced by the frequency of 
suicide at a post in Northern Arizona, called in the army " Sui- 
cide Post." Four officers attempted suicide there, and even one 
Indian, which latter was a very unusual occurrence. This post 
is no miles from a railroad, and is situated near a dark canyon, 
at t,he foot of a high lava mountain, which occludes the sun at 
4 p. m. This gloomy environment is doubtless a contributory 
factor. Bluntness is sometimes helpful in dissuading a suicide. 
This is illustrated by the story of a rough and ready old army 
colonel in whose command a suicide epidemic appeared. He 
called for one man suspected of contemplated suicide and roughly 
told him that if he wanted to shoot himself he should go out on 
the lot and do it, instead of messing up the barrack room floor. 
The result was that the man decided not to commit suicide. 

Dr. L. Pierce Clark said that he believed that the personal 
morale and sense of identity in the country constitute a factor 
against suicide as compared with looseness of standards in the 
city. He had been impressed with a peculiar psychology in some 
depressives. They seem to have a sense of separation from God, 
by reason of sin. and plan suicide with expiational intent. If 
they are rescued, and if the intent was sincere, they feel that 
they have done, as it were, all they can, and have thereby atoned. 
Thereafter they get well. If they do not make a sincere attempt, 
they still feel they have to go through the ordeal, and they do 
not improve. Might this not suggest the advisability of letting 
these persons really attempt suicide, taking precautions to rescue 
them, so that they can gain this sense of rehabilitation which 
helps in their cure? This should be carefullv studied. In regard 
to the many patients at Bellevue. some of these persons confess 
that no one is left to really love them. This means that the out- 
stream of the libido has lost its attachment and has resulted in 
attempted suicide, and extreme gesture of despair. 

Dr. Kempf said he was inclined to take issue with Dr. Salmon 



NEW YORK NEUROLOGICAL SOCIETY in 

regarding - methods. He felt that often the part of the body is 
attacked which is associated with some pain or discomfort, as, 
for instance, in the case of a man who complained of intense 
headache and shot himself through the head; and one young 
woman who suffered precordial pain, shot herself through the 
heart. 

Dr. Wechsler said that in some cases, such as the hebephrenic 
types, the impulse has no logical basis. 

Dr. Foster Kennedy said that psychological facts are often 
expressed in the lay literature. Benson wrote of a stranger in 

London feeling so " D d anonymous." In regard to the 

A. E. F., men who wanted to commit suicide put themselves in 
murderous positions in the front line. In Europe the method 
by drowning seems more popular than other methods, and has 
no seasonal variation. In studying the suicide rate in Saxony, 
compared with that of Ireland (358 against 17 per 100,000), it 
would seem that there must be something more than individual 
variation. 

Dr. Salmon, in closing, said that the increase of suicide has 
no doubt something to do with the choice of methods. There is 
avoidance of mutilation by women and the preference for fire- 
arms by men. In the army, shooting is often chosen because it 
is considered more or less a soldier's death and somewhat 
removes the stigma. In regard to the story of the blunt colonel, 
doubtless the frankness was useful in preventing the issue. In 
regard to the A. E. F., it must be remembered that only 60 per 
cent of the men were actually under fire. Some general cause 
must have operated to lower the suicide rate as after the armis- 
tice it resumed the former proportion. In regard to loneliness 
in the country, that cannot be compared to loneliness in a large 
city. There are at present 75.000 ex-service men in New York 
whose homes are distant. That must have some effect in 
increasing city loneliness. Non-mental cases are of peculiar 
interest. The subject is very large and it is impossible to touch 
more than the outline. The best method of study is the careful 
detailed case study of the patient who has been rescued from 
attempted suicide. There is a rarity of second attempts. Some- 
thing has occurred in the life of the patient along the line sug- 
gested by Dr. Clark. Often the suicide finds his first friends in 
the hospital. He is clapped on the back and the friendly, demo- 
cratic atmosphere increases the homely, human resources of the 
hospital and adds to its therapeutics. The days of statistical 
study alone, and of the measurements of skulls and ears are past. 
When we carry out careful, detailed study of living cases, as a 
routine measure, we shall know more about the psychology of 
suicide than we do to-night. 



U2 NEW YORK NEUROLOGICAL SOCIETY 

IODIDES, OBSERVATIONS UPON THEIR USE AND 

VALUE, INTRAVENOUSLY. 

Dr. Frederick J. Farnell. 

[Author's Abstract.] 

Comment: Can it be that tissue and cell changes can be more 
rapidly brought about by giving a highly concentrated solution 
of sodium iodide directly into the blood stream? 

Could the same result be obtained by giving a concentrated 
solution along with a bland syrup, by mouth? 

Do the apparently good results depend upon the high concen- 
tration or upon the intravenous channel of administration? 

Summary: Iodine in the form of an iodide can be given in 
hypertonic form intravenously. 

Iodine when given into the blood stream in hypertonic form 
has a tendency to reduce the idiosyncrasy towards iodism. 

Iodides introduced into the blood stream appear to readjust 
systemic fungus disturbances (oidiomycosis) very rapidly. 

Iodides intravenously in concentrated form appear to help 
materially the action of salvarsan upon the diseased tissue and 
cell. 

Iodides introduced into the blood stream in hypertonic solu- 
tions probably have some influence upon reducing the edema, 
hyperaemia, etc., of the brain in increased brain bulk disorders. 

Discussion : Dr. Smith Ely Jelliffe said that he was called 
upon once to write a book upon pharmacology and therapeutics, 
and also to lecture upon the subject, hence his special interest 
in Dr. Farnell's presentation. In recent years he had noted a 
definite restoration of the subject to a place of respect in teach- 
ing and to a renewal of interest in the action of drugs on the 
human body. Pessimism is receding and a healthier pharma- 
cology advancing. The role played by iodine in the body is 
extremely important. The iodine mechanisms are extremely 
intricate and only partly analyzed, the chief question opened up 
being the iodine content of the thyroid. He had hoped that Dr. 
Farnell would touch upon the action of iodine on the sympa- 
thetic side of the arc of the vegetative nervous system. The 
vegetative nervous system is definitely affected by iodine, chiefly 
on the sympathetic side. This in turn influences body metabol- 
ism. Dr. Farnell has approached the subject from a different 
angle — that of specific disorders. 

Dr. J. H. Leiner said that in regard to the combination of 
iodine with salvarsan medication, there is now a routine practice 
of this method in Vienna. It is seen that iodine enhances the 
effect of salvarsan given intravenously. 

Major Jarvis (by invitation) said that Dr. Nicholas Senn 
of Chicago had noted the absence of tuberculosis and of skin 
diseases among the Esquimaux. This he thought due to the 
large amount of iodine in the blubber and fish which form their 



NEW YORK NEUROLOGICAL SOCIETY 113 

staple food. These people fall prey to tuberculosis and respi- 
ratory diseases when they come to a temperate climate. 

Dr. Foster Kennedy said that Hoover put an end to the epi- 
demic of adolescent tuberculosis by increasing the fat ration in 
Vienna. 

Dr. Farnell, in closing, said that this work was experimental. 
He first tried giving large doses of potassium iodide intravenously, 
but it caused thrombosis from irritation of the vein lining. He 
then tried injection of 400 grains of sodium iodide in a case of 
oidiomycosis. The patient was comatose for a day, but recov- 
ered without any ill effect. The man was cured of lesions of the 
lung and of the central nervous system. The sodium salt injec- 
tion was apparently harmless. 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY. 

Regular Meeting, November 17TH, 1921. 

Dr. James B. Ayer, President, in the Chair. 



SCHIZOPHRENIC DETERIORATION. BIO - CHEMICAL 
STUDIES AND PRESENTATION OF CASE. 

Dr. Karl M. Bowman presented a boy of 15, who came for 
treatment because he was nervous, losing weight, weak and not 
getting along well. His father had a somewhat similar condition 
when he was this boy's age, but apparently recovered and has got- 
ten along fairly well in life. This boy has always been sensitive 
and has shown seclusive traits. He has never been rugged and has 
been physically afraid of other boys. In December, 1920, the boy 
commenced to lose weight. He is much wrapped up in his own 
thoughts and it is not entirely clear just what these ideas are. The 
tendency to day dreaming is not very far advanced. He complains 
of dizziness, poor appetite, headache and various bodily symptoms. 
He has had fits of irritability during which he has broken some 
things, and also spells of crying. 

The physical examination shows that he is not well developed, 
has poor expansion, blood pressure is 115/78. His fingers are long 
and graceful. He has no axillary hair and pubic hair is of the 
feminine distribution. General medical examination negative. Basal 
metabolism on four different examinations was — 24, — 31, — 37, and 
then, following the feeding of thyroid extract — one grain a day 
for two weeks — the last reading was — 25. X-ray of the sella was 
normal. The blood chemistry was within normal limits. Spinal 
fluid negative, urine negative, blood negative. Hemoglobin 85%. 

A further investigation along these lines is shown by a chart 
which gives the results of testing nine cases of dementia praecox, 
seven of which are of the paranoid type and two of which are hebe- 
phrenic. They are all cases of long standing. It was felt that 
laboratory studies over a certain series of cases might reveal the 
possibility of certain definite laboratory findings which would be 
constant in all cases. Consistently negative findings would be an 
equally valuable observation or even a marked scattering of results 
would be valuable. Twenty-four hour specimens of urine were 
examined quantitatively for acidity, total nitrogen, ammonium 
nitrogen, uric acid and chlorides. Some of the findings were low 
and some were high, and there was no constant feature in the urine 
findings. This merely confirms Dr. Folin's findings as far back as 
1904-5, for the work he did then in urine studies was interpreted 
in much the same way. Next the blood chemistry was studied. 
Quantitative examinations of the non-protein, nitrogen, dextrose, 
uric acid, chlorides, and carbon dioxide combining power were 

114 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 115 

made. In the non-protein nitrogen test all but one fell within nor- 
mal limits. In the dextrose test three were above normal limits and 
there seemed, perhaps, a tendency for the sugar to run higher than 
normal. In the uric acid test the findings were within normal limits. 
In the test for chlorides the findings except two were within normal 
limits and those were very close to it. The carbon dioxide com- 
bining power of the blood was within normal limits. The blood 
sugar tolerance curves showed great variation with no constant type 
of curve, but a considerable number were definitely abnormal. The 
basal metabolisms were done. Two were between o and -{-$, and 
the rest fell below o. One was — 8. Three were between — ioand — 19 
and two were — 20 and one was — 27. This was of some significance 
and in view of the case presented it would seem that this point is 
worthy of further investigation. The renal function test was done 
and showed the lowest result as 62% ; all were, therefore, quite 
normal. The Goetsch test was entirely negative in every case. The 
hemoglobin was tested in all cases and the findings were entirely 
within normal limits. The red counts were high, the white normal. 
We felt that in reviewing these findings we had a very definite 
tendency of the basal metabolism to fall below the normal and we 
had a large number of abnormal sugar tolerance curves, but no con- 
stant picture. The other findings all seemed essentially negative. 

Discussion : Dr. C. Macfie Campbell said that the observations 
are of great importance, because in these deteriorating cases one is 
dealing with a type of disorder which is of great severity, extremely 
frequent, and of great social importance. After all, the greater 
number of patients for whom the State is responsible, are those 
cases of deterioration of which this boy is one type, and therefore, 
it is one of the most important of problems. The tendency in study- 
ing these cases has varied from time to time. If auto-intoxication 
was in vogue, the physician looked for auto-intoxication. Focal in- 
fections came up and the teeth were taken out and the individual 
was well pruned. The libido later claimed attention and the libido 
was traced by some from its genesis to its maturity. There are few 
patients who have been studied in their entirety. As a rule the pre- 
sentation of a case has been from one aspect. Perhaps of the great- 
est importance at the present moment, is the study of such patients 
in toto, to see if at the root of their emotional difficulties there may 
not be some disorder which may be formulated in simpler terms. 
Each man is different from his neighbors. Is one to formulate the 
constitutional traits and . maladaptations in complex terms of the 
emotional life or can a key be found to these traits and to the dis- 
order in metabolism or the chemical energies of the system? This 
patient is studied from this standpoint and his basal metabolism is 
found to be low. Is that one of the fundamental component factors 
which produce the total fault? In his emotional life is his limi- 
tation (lack of plasticity of the libido) largely due to the fact that 
some of the elementary components are lacking? The time may 
come when the etiology of these disorders is not sought in one popu- 
lar formula or another but an effort will be made to understand the 



u6 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 

constitutional endowment of the individual both in its simple and 
complex factors. 

Dr. W. B. Swift said he hoped that something will be done with 
the speech in cases like this. When working in the Psychopathic 
Outpatient Department, he had 1 made a series of speech tests on ten 
patients of each psychosis. He found new and as yet unpublished 
signs in speech in all except one, and in general paresis, four or five. 

Dr. J. B. Ayer asked Dr. Bowman if he had succeeded in raising 
the metabolism of these patients showing a low rate, what he had 
used, and with what success. 

Dr. Donald Gregg asked if an early tuberculosis infection had 
been looked for in this case. Tuberculosis would give more or less 
the same picture. 

Dr. Bowman, in closing, answering Dr. Ayer, said that in only 
one case was an attempt made to raise the basal metabolism. One 
started with one grain of thyroid and then the patient decided that 
yeast would do him more good than thyroid. He did not believe the 
sugsr tolerance could be interpreted. In diabetes the sugar curve 
mounts up at the end of the first hour and does not return to normal 
at the end of the second hour. In certain endocrine disturbances, 
in hyperthyroidism and hyperpituitarism there is this diabetic curve. 
In hypothyroid and hypopituitary conditions there is the exact op- 
posite type of curve for at the end of the first hour there is almost 
no rise in the blood sugar and at the end of the second hour it is 
entirely back to normal or below normal. It is claimed by certain 
writers that there is a typical curve in dementia praecox. Their 
report does not confirm these findings. As regards the findings in 
early tuberculosis, there should be a certain amount of fever. In 
that case the basal metabolism would be definitely increased and not 
decreased. 

HYSTERIA AND PERSONALITY. 

Dr. Martin W. Peck presented a girl of nineteen, who had 
been admitted to the Psychopathic Hospital six months previously, 
with nearly complete hysterical paralysis, aphonia, and a mental 
state of anxious,- fretful hypochondria. There was a history of two 
similar attacks during a period of two years. After two months 
without change, she suddenly recovered and has been ever since in 
robust physical health and without somatic complaints. At the same 
time she developed a type of disagreeable behavior which has kept 
things in a turmoil, and has made it impossible for her to return 
home or get on in other than hospital environment. She appears to 
derive her main satisfaction in teasing, ridiculing and interfering 
with those about her, but it is all done in a mischievous and semi- 
playful, rather than malicious manner. She also indulges in much 
troublesome horse-play, and is tiresomely talkative. Her past his- 
tory proves that this conduct represents in a general way, her usual 
state since childhood. In play and in school, she did not get on with 
her mates, at home she antagonized the neighbors ; and her working 
career included frequent changes of position and continuous petty 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 117 

friction of her own making. She shows lack of normal affection 
and absence of serious purpose in life. In appearance she is attrac- 
tive and graceful ; she has normal intelligence and considerable 
artistic ability. At no time has she been delinquent in the usual 
tense of the term, or shown tantrums of any order. While friendly 
enough toward physicians, it has never been possible to establish 
sufficiently frank relationship to unearth the deeper factors in her 
character difficulties. The case was discussed from the standpoint 
of descriptive analysis and her personality defects outlined by group- 
ing them in the fundamental spheres of reproductive, herd and self- 
preservative activities. 

Discussion : Dr. H. C. Solomon asked Dr. Dewey and Dr. 
Walton what their attitude would be toward the question of the 
commitment of this girl. Would they be willing to go before a court 
and ask for her commitment. 

Dr. G. L. Walton said he should not be willing to commit her 
without further investigation. She appears like a high grade im- 
becile. She has a hypermanic tendency, a lack of moral sense and 
pleasure in disturbing other people. 

PRESENTATION OF CASES OF ORGANIC PSYCHOSIS 
(LETHARGIC ENCEPHALITIS). 

Dr. Lloyd T. Thompson said that in the past two months, at 
least five cases had been seen in the Psychopathic Hospital, in which 
the diagnosis of encephalitis lethargica is the most probable one, but 
owing to the fact that there is no epidemic of this disease at the 
present time, and that these cases are somewhat atypical the final 
diagnosis of that disease has not been made. The two cases pre- 
sented were especially interesting because of the psychotic symptoms 
shown in addition to marked and changeable neurological dis- 
turbances. 

Case I. A man 49 years of age, who was admitted with a com- 
plaint of tremor of the right arm and weakness of the entire right 
side. The onset was sudden, five weeks before admission, with dizzy 
spells, tremors, headache and dull pain over entire right side. At 
one time there was blurring of vision. On admission patient had a 
mask-like facies with weakness and hypesthesis of left side of face. 
Pupils were unequal and irregular but reacted normally. There was 
a coarse tremor of right arm and hand with weakness and inco- 
ordination on right side. Deep reflexes more active on left with 
Babinski on left. Reaction to pin prick lost on right side. The 
neurological picture was very changeable from day to day. A 
double ptosis and paralysis of left internal rectus developed. Re- 
peated lumbar and cistern fluids showed only a consistent increase 
in the sugar content. 

Patient was somnolent in the morning but became active toward 
evening. He became hallucinated and developed ideas of perse- 
cution. At one time he presented a typical manic condition with 
flight of ideas, elation, overactivity, etc. He was correctly oriented 
but showed impairment of memory and judgment. 



n8 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 

Case II presented a similar history and changeable neurological 
disturbances, but the mental condition was somewhat different. On 
admission he resembled very closely a case of catatonia with sudden 
outbursts of aimless excitement. A few days later he changed and 
seemed more like a depression. He admitted that he was very un- 
happy and worried and there was marked retardation. Patient was 
hallucinated and had self accusatory ideas, but these symptoms have 
now disappeared. These cases were presented to point out the pos- 
sibility of sporadic encephalitis or the possibility that they may be 
the beginning of another epidemic. They also serve to illustrate the 
prominence of mental symptoms and the close resemblance to other 
forms of psychoses. 

Discussion: Dr. H. I. Gosline asked what was the actual read- 
ing of the gold sol. It has been reported that the gold sol did show 
something specific in cases of encephalitis lethargica. 

Dr. D. J. MacPherson asked to what extent is it true that in- 
creased sugar is present in encephalitis lethargica? 

Dr. Harold E. Foster said that in the series which were in the 
Massachusetts General Hospital, increased sugar was a very con- 
stant sign. It was present in all cases. An interesting feature was 
that in the fatal cases the spinal cord sugar ran markedly high. It 
also ran very high in an encephalitis case with acute retention. 
Syphilitic cases, especially general paresis, run fairly high, but not 
as high as encephalitis, although they may overlap. In laboratory 
work it cannot be said that any one thing will make the diagnosis. 
The diagnosis of encephalitis can be questioned in any case that has 
run for any length of time with a normal spinal fluid sugar. 

Dr. Thompson said that the gold sol readings were actually nega- 
tive except for a few changes to " ones." There is no characteristic 
reading for encephalitis. It may be anything from a negative to a 
" paretic curve " reading. However, the changes that do occur are 
in the first five or six tubes and very seldom in the tubes of greater 
dilution. 

HISTOLOGICAL EVIDENCE OF THE RESULT OF 
TREATMENT OF GENERAL PARALYSIS. 

Dr. Harry C. Solomon and Dr. Annie E. Taft read this paper. 
The object of their investigation was to determine if treatment of 
cases of general paralysis produced any effects that might be ob- 
served histologically. For this purpose a histological examination 
was made of the brains of twenty-seven patients having had general 
paresis to whom treatment had been given. These were compared 
with a series of fourteen untreated cases. Sections were taken from 
twenty-four areas in each brain ; sections were stained by cresyl 
violet. Realizing that the histological picture varies from different 
areas of the same brain, the twenty-four areas were studied from 
each brain and thus a fair idea of the situation could be obtained. 

One striking feature of general paresis is the presence of plasma 
cells in the perivascular infiltrations and in the meninges. It is 
pretty generally accepted that plasmacytosis is essential for a diag- 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 119 

nosis of general paresis. A lantern slide picture was shown from a 
case of untreated general paresis showing a small vessel surrounded 
by an infiltration consisting almost entirely of plasmacytes. A second 
picture was shown from a case of general paresis that had received 
treatment. Vessels here showed some perivascular lymphocytic in- 
filtration but no plasma cells. This was said to be the rather char- 
acteristic finding that differed in the treated and untreated cases, 
namely in the treated cases plasmacytes were comparatively rare as 
contrasted with the untreated cases. 

The results of the examination of twenty-seven cases receiving 
treatment were charted. Sixteen of the twenty-seven cases showed 
practically no plasmacytic infiltration. Six showed a moderate 
amount, and five showed a considerable amount. Of the five that 
showed considerable plasmacytic infiltration two or three had a fair 
amount of treatment and. the other two had very little. Contrasted 
with this finding in the treated cases were the findings in the un- 
treated series of fourteen. Of the fourteen untreated cases, nine 
showed a considerable degree of plasmacytic infiltration, and five a 
moderate amount and none of them showed a very slight infiltration 
as was found in the sixteen of the twenty-seven treated cases. The 
story concerning the perivascular lymphocytic infiltration is similar 
but not so marked. Twelve of the twenty-seven treated cases 
showed a slight infiltration, ten a moderate amount, while five 
showed considerable. It is worth noting that a number of the cases 
showed a fair amount of lymphocytic infiltration and very slight 
plasma cell infiltration. In the series of fourteen untreated cases 
not one was relatively free from lymphocytic infiltration, whereas 
nine showed a moderate perivascular lymphocytic infiltration and 
five showed a marked infiltration with lymphocytosis. A number of 
the brains had had the pia stripped before being obtained for ex- 
amination. However, there were nineteen of the treated cases which 
had the pia intact. Of these, nine showed a slight pial infiltration, 
seven moderate, and three considerable. In eleven of the untreated 
cases it was possible to examine the meninges. Of these, one showed 
slight pial infiltration, four moderate, and six considerable. As re : 
gards the pial infiltration it is rather striking to find that three of 
the treated cases had a considerable amount of pial infiltration with 
lymphocytes. A priori, it would seem that the pial inflammation is 
readily amenable to anti-syphilitic drugs but histological evidence in 
these cases points to the fact that there are cases in which the anti- 
syphilitic remedy does not give satisfactory results even as regards 
the pial infiltration. As to the glia cell picture there was no evidence 
of difference between the treated and untreated cases. One would 
feel that from the differenc in the type of the plasma cell picture it 
is possible to make a fair estimate by a histological examination as 
to whether the cases had received anti-syphilitic treatment. They 
believe they are justified in drawing the conclusion that something 
has been accomplished by the treatment of cases of general paresis 
as shown by the histology, even though this may not have any clini- 
cal value. 



120 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 

Discussion : Dr. H. I. Gosline said that one slide seemed to 
show a certain paucity of nerve cells. Have such areas in treated 
cases been compared with similar areas in untreated cases? His 
reason for asking that, is that he had noticed in carrying out this 
treatment, that neoarsphenamine will start a severe dermatitis and 
lead to cicatrization if one does not cover the fingers. Then again 
the cell count drops as a most constant and uniform occurrence. 
Does this arsenic act as a sort of searing process, killing off epithe- 
lial cells, and does the cured paretic get on because he has a suffi- 
cient number of nerve cells left to function although he has been 
injured ? 

Dr. Donald Gregg asked what happened to the ten cases under 
treatment that were reported on a year ago? 

Dr. Solomon said one of them has had a relapse. 

Answering Dr. Gosline's question, he said these cases had been 
studied in a great deal more detail than he had attempted to show 
this evening. The glia cells, the white substance, the ventricular 
surfaces, the dropping out of cells, were studied and they had at- 
tempted to see if there were any relation to the age of the patient 
or to the duration of the process. He did not believe they would 
have any very striking results. Why some cases die with a small 
amount of atrophy and some with a tremendous amount is unknown 
to him. As to the spinal fluid findings, some rather disappointing 
results have occurred. Some of the cases in which the spinal fluid 
was practically free of cells during life show marked evidence of 
meningeal and perivascular infiltration. In one case particularly, in 
which apparent cure had been accomplished, the serology was en- 
tirely negative, yet there was perivascular infiltration and meningeal 
involvement. Dr. MacPherson asked whether it was a good thing 
or a bad thing to lose one's plasma cells when one has paresis. He 
did not know. The fundamental study they would like to make, 
would be on the amount of spirochetosis these brains show, but this 
is not possible at present, due to the technical difficulties in demon- 
strating spirochetes. 



Current Literature 



VISCERAL NEUROLOGY. 
1. VEGETATIVE NERVOUS SYSTEM. 
Albert Kuntz and 0. V. Batson. Experimental Observations on the 

Histogenesis of the Sympathetic Trunks in the Chick. [Jour. 

of Comp. Neurol., 1920, xxxii, December, 335.] 

As the findings of Kuntz that cells of medullary origin play an im- 
portant part in the development of the sympathetic nervous system have 
been doubted by others, he and Batson have tried by crucial experiments 
to eliminate the neural crest and the dorsal portion of the neural tube 
before the spinal ganglia have become differentiated: if this could be 
done, and it were still found that the embryo continues to develop with- 
out spinal ganglia and dorsal nerve-roots, the remaining portion of the neu- 
ral tube would be the only source from which cells of nervous origin 
could migrate along the paths of the spinal nerves. If in such embryos 
the primordia of the sympathetic trunks should arise they would of 
necessity arise from cells which migrate from the neural tube along the 
paths of the ventral roots of the spinal nerves. In these experiments 
chick embryos were subjected to operation at the close of the second day 
of incubation (48 hours), at which time the spinal ganglia are not yet 
differentiated : the dorsal portion of the cerebrospinal nervous system 
was destroyed by electrolysis throughout a limited portion of the trunk 
region. By this means the writers obtained conclusive evidence that 
cells of medullary origin, which advance peripherally along the ventral 
roots of the spinal nerves, enter the primordia of the sympathetic 
trunks. The spinal ganglia are not excluded as a source from which 
cells may enter the primordia of the sympathetic trunks under normal 
conditions; however, these primordia may arise from cells derived from 
the neural tube only, at least when cells which have their origin in the 
spinal ganglia (or neural crest) are excluded. 

" As observed above, the primordia of the ganglia of the sympa- 
thetic trunks may be approximately of normal size in segments in which 
the spinal ganglia and dorsal nerve-roots are absent, but the remnant 
of the neural tube is relatively large. On the other hand, these pri- 
mordia are small or entirely absent in segments in which the remnant 
of the neural tube is small and represents only the most ventral por- 
tion of the central nervous system, even though ventral nerve-roots are 
present. These facts suggest that the cells which normally give rise 
to the ganglia of the sympathetic trunks are derived largely from those 
portions of the walls of the neural tube which give rise to the lateral 

121 



122 CURRENT LITERATURE 

cell-columns. Theoretical considerations also favor this interpretation; 
however, we do not feel that the evidence at hand warrants a definite 
conclusion on this point." [Leonard J. Kidd, London, England.] 

Kuntz, A. The Development of the Sympathetic Nervous System 
in Man. [Jour. Comp. Neur., October 15, 1920] 

From a study of embryological material, Kuntz shows so far as 
ontogeny can show that the primordia of the sympathetic trunks arise in 
human embryos of about 5 mm. They first show as a small group of 
cells lying along the dorso-lateral aspects of the aorta in the lower 
thoracic and upper abdominal region. Six mm. embryos show them 
from the lower cervical to the sacral region. When the embryo reaches 
a length of 10 to 11 mm., the primordia are then noted in the upper 
cervical region as well. These primordia arise from cells of cerebro- 
spinal origin advancing peripherally along the dorsal and ventral roots 
of the spinal nerves. The vagal sympathetic plexuses arise in similar 
fashion and advance along the vagi. The more distal enteric plexuses 
arise from cells derived from the sympathetic supply in the lower 
trunk region. The ciliary ganglion is derived from the semilunar gang- 
lion via the ophthalmic nerve. The primitive cells of the spheno- 
palatine ganglion advance along the greater superficial petrosal nerve, 
originating also from the semilunar ganglion via the maxillary nerve. 
The otic ganglion arise at the growing extremity of the lesser superficial 
petrosal nerve. The petrosal ganglion also receives cells of trigeminal 
origin via the mandibular nerve. The submaxillary and sublingual 
ganglia arise on the lingual nerve primarily from cells of trigeminal 
origin. They probably receive some cells of facial origin via the chorda 
tympani. The smaller ganglia on the glossopharyngeal nerve in the 
.posterior portion of the tongue arise from cells which advance into the 
tongue along the glosso-pharyngeal fibres. The cells which give rise to 
sympathetic neurones are derived from both cerebro-spinal ganglia and 
the neural tube. Not all of those cells actually migrate as such, as 
many arise by mitotic division of the migrant cell along the paths of 
migration and in the primordia of the sympathetic nervous system. 

Eyster, J. A. E., Middleton, W. S. Auriculo- Ventricular Heart- 
Block in Children. [Amer. Jour. Dis. Child., February, 1920.] 
Twenty cases of heart-block in children, nearly all of which were 
definitely or probably of congenital origin or occurred during the course 
of severe and usually fatal diphtheria, are here reported upon. A per- 
sonal case of partial auriculo-ventricular dissociation is added. This 
developed in a child of 2, apparently in connection with an acute nose 
and throat infection in which the cultures showed only Staphylococcus 
pyogenes aureus. The child, who was kept under observation for two 
years, developed normally. At the time of writing the cardiac condi- 



VISCERAL NEUROLOGY 123 

tion was that of a well compensated mitral lesion associated with a 2 to 1 
auriculo-ventricular block, with a ventricular rate between fifty and 
sixty. 

G. C. Bolten. The Vaso- Vagal Attacks of Gowers. [Psychiatrische 

en Xeurologische Bladen, 1920, No. 5-6, 341.] 

The vaso-vagal attacks described by Gowers are not very common. 
Bolten agrees with Gowers that they are closely related to epilepsy. 
These patients are almost always very neuropathic ; their attacks occur 
mostly suddenly, at times apparently wholly spontaneously, at others in 
connection with exposure to cold or cold-stimuli. There is violent pal- 
pitation, the patient is tormented with a very severe and troublesome 
feeling of oppression, cold, " dead " extremities, paraesthesiae in hands 
and feet, and a great retardation of the line of thought. During the 
attack the patient is not unconscious, yet he feels that he cannot move 
his limbs; there is great inhibition of all psychical processes, and speech 
is impossible on account of a complete stiffness of the jaws, and in all 
four limbs he feels great tingling as if he had been sleeping on his arm 
or leg. In spite of the preservation of consciousness he can think only 
very imperfectly ; he can assimilate all kinds of external impressions, but 
all the associational processes in his brain are strongly inhibited. So 
severe is the oppressed feeling that it brings him into a state of great 
anxiety, so strong that, even although he may have had many previous 
attacks, he feels always that he will die in this attack (apparently death 
has never occurred in an attack). Bolten records a case very graphic- 
ally, and discusses the nature of these vaso-vagal attacks at length. He 
holds that they are very closely related to angina pectoris vasomotoria 
and to paroxysmal tachycardia. He strenuously denies that they are the 
sequel of a simple peripheral disturbance (vascular contraction or 
spasm), but holds that they are due to a more complex constitution- 
anomaly, viz., a vasomotor insufficiency. In these three types of attacks 
— which he regards as merely mutual variants — the usual considerable 
pulse-acceleration he looks on as a compensation-symptom; by increas- 
ing the number of ventricular contractions — which are in part true 
extra-systoles — the organism attempts to compensate for the harmful 
effect of the low blood-pressure. Bolten concludes that the vaso-vagal 
attacks of Gowers do not form an independent clinical entity, but are 
to be conceived of as a non-essential variant of paroxysmal tachycardia 
and of "pseudo-angina" (angina pectoris vasomotoria). [Leonard J. 
Kidd, London, England.] 

F. Depisch. Pathology of the Vegetative Nervous System. [Wien. 

Archiv. f. innere Medizin, March, 1920, 1, 1.] 

A unilateral vegetative nervous system syndrome is here described by 
the author. He tries to show by it, in comparing with others, that the 



124 CURRENT LITERATURE 

fibres of the vegetative system become crossed on their way to the per- 
iphery in a somewhat analogous manner to the somatic sensori-motor 
systems. The primary lesions causing such unilateral symptoms are 
usually some localized hemorrhage in the medulla oblongata, entailing 
bulbar paralysis. The unilateral symptoms included a higher local 
temperature, the unilateral action of drugs, pilomotor reflex variations, 
sweat differences, etc. 

Andre-Thomas. The Pilomotor Reflex. [Rev. Neurol., 1920, 27, 

1 139] 

Andre-Thomas describes the receptive field, appropriate stimuli, and 
the characters of the response in this reflex under various conditions. 

In the normal subject the pilomotor muscles may be excited directly 
by mechanical stimuli or reflexly. As a reflex it may be obtained by 
various stimuli applied to the skin, such as cold, friction, and the elec- 
tric current. To unilateral stimuli the response is unilateral and may 
spread to the whole of the stimulated half of the body, or it may be 
restricted to one or more segmental areas. Certain cutaneous areas are 
particularly receptive, the nape of the neck and shoulders and the 
lower part of the axilla. When elicited from the neck the response is 
descending, and stronger stimuli are necessary to produce it over the 
head and neck. On the limbs, the extensor surfaces give the response 
more readily than the flexor surfaces. Bilateral stimuli produce a 
bilateral response. 

In lesions of the spinal cord the response is exaggerated immediately 
below the upper level of the lesion. In total divisions of the cord, 
there are two forms of response: one above the level of the section, the 
" reflexe encephalique," and one below, the " reflexe spinale." 

The spinal reflex in total divisions of the cord makes its appearance 
when the isolated portion of the cord emerges from the spinal shock — 
that is, simultaneously with the mass reflex. It is elicited by the same 
stimuli as this reflex, namely, passive movements of the legs, etc. In 
these circumstances, the factors governing the distribution of the spinal 
reflex are the same as those governing that of the reflex sweating 
described by Head and Riddoch — that is, the distribution of the tho- 
racico-lumbar white rami. 

In partial lesions and in various diseases of the spinal cord, the 
response varies and is often difficult of interpretation. It is normal in 
poliomyelitis. In syringomyelia, variations in the response follow the 
distribution of vasomotor and trophic disturbances. In peripheral nerve 
lesions, the reflex response is abolished over the area of sensory changes, 
but, as Trotter and Davies showed, a local response to stimulation 
persists. 

The cerebral reflex, that is, the response above the level of a cord 
lesion, varies greatly in facility and distribution. It descends to the 
level of the sympathetic distribution of the isolated portion of the cord. 



VISCERAL NEUROLOGY 125 

In the normal subject the reflex is elicited by peripheral stimuli and 
also by various emotional states. The quality of the stimulus in both 
cases is similar and is strongly affective. In the former case, the sen- 
sations aroused by stimulation are of the affective variety and are 
unpleasant. Hence when the skin is anaesthetic no response can be 
obtained from it. The emotions producing the reflex are also unpleas- 
ant in quality. Fright and horror are the most adequate stimuli, but 
any profound emotion, whatever its quality, may be sufficient to pro- 
duce it. The reflex of emotional origin is bilateral, that due to per- 
ipheral stimulation may be unilateral. The pilomotor reflex may there- 
fore be regarded as an affective reflex. [F. M. Walshe in Medical 
Science.] 

Rizzo, C. The Ciliary Ganglion and Inactivity of the Pupil. 
[Arch. biol. norm. e. patol. 1920, 74, 1.] 

The much discussed problem of the pupillary reflexes is here taken 
up. With regard to the seat and nature of the lesion underlying the 
Argyll-Robertson pupil (alone, or associated with inactivity to accom- 
modation), he quotes Marina and others as having asserted that in this 
condition the cells of the ciliary ganglion are reduced in number, and 
show chromatolysis, and that the myelin sheaths of the ciliary nerves 
are degenerated. Other observers, notably Andre-Thomas, have been 
unable to confirm this from the investigation of three cases. The author 
agrees with Andre-Thomas. He examined the ganglia from nine nor- 
mal subjects, from eight paretics and one tabetic with Argyll-Robertson 
pupils, from two paretics with totally inactive pupils, and from one with 
defective reactions to both light and accommodation, and from one 
paretic with normal pupils. He failed to find any noteworthy degenera- 
tion of the nerve-cells, though a few cells showed some chromatolysis 
and swelling of the cytoplasm which were obviously acute and recent 
lesions attributable to the intercurrent illness which caused death. The 
roots of the ciliary ganglion, the short ciliary nerves, the nerve plexus 
of the muscle of Brucke, and the nerve filaments of the iris and cornea 
were all normal in every case. An exudate of lymphocytes and plasma 
cells was constant in the ganglia of paretics. 

Fraikin. Solar Plexus Sign with Abdominal Neuropathies. 

[Paris Med., February 14, 1920, 10 No. 7.] 

Spontaneous pain or tenderness in the solar plexus is a not infre- 
quent result of disturbance of the plexus. It is a sign that the circula- 
tion is hampered in or outside of the viscera, or the nerves are suffer- 
ing from toxic action or from traction from sagging organs. This 
solar sign may serve to differentiate a psychogenic conversion pain, from 
a somatic visceral lesion. 



126 CURRENT LITERATURE 

Livierato, P. E. The Abdominocardiac Reflex. [Grece Med., Athens, 
Dec, 1920. J. A. M. A.] 

Livierato reports that his own and others' extensive experience has 
confirmed the instructive increase in the size of the right ventricle by 
mechanical stimulation of the abdominal nerves. He taps along the 
median line in the epigastrium, the patient recumbent, the abdominal 
walls relaxed. The left ventricle shows no change, and there is no 
change in the healthy, but when the heart elasticity is below par, the 
right ventricle enlarges from this tapping, and it is thus a very useful 
sign of the condition of tonus of the myocardium, revealing insufficiency 
before it has become manifest in any other way. This reflex was 
always positive in patients convalescing from various diseases. Livie- 
rato reports further that when the right heart shows spontaneous dila- 
tion on changing from the recumbent to the erect posture, this is like- 
wise a sign of hypotonicity of the myocardium. The dilation subsides 
spontaneously as the subject reclines again. This spontaneous increase 
of the heart area upward and to the right on change from the horizontal 
to the erect posture is always a sign of pronounced hypotonicity of the 
heart muscle. 

Ant. Hutter. A Case of Myasthenia Gravis. [Psychiatrische en 
Neurologische Bladen, 1920, Nos. 5-6, 352, (6 figs.).] 
The patient, a man of twenty-five, was a typical case of myasthenia 
gravis, with attacks of fatigue, extending over two and a half years, 
interrupted by remissions. In the attacks there were also bulbar symp- 
toms and the myasthenic reaction. Death took place from a pulmonary 
lesion complicated with rapid exhaustion of respiratory and auxiliary- 
respiratory muscles. Necropsy showed microscopically a normal brain 
and a strikingly small pituitary. In the thymus-region there was a small 
fatty lobe; the vocal cords showed a mother-of-pearl glistering. Thy- 
roid gland rather small; tongue appears fatty. A very fatty omentum. 
Spleen rather large, greenish, and shows plainly on section its follide- 
pattern; its pulp is swollen. Liver rather light-colored. Kidney very 
vascular, with strongly developed fai- capsules. Right adrenal very vas- 
cular; left very flabby, its cortex appears too thin. Prostate rather 
large with definite middle lobe. Microscopically, the central nervous 
system was normal; so also were the thyroid, adrenals, testis, pituitary, 
spleen, kidney, stomach, pancreas, and prostate. Tongue-muscle fatty. 
Rich lymphoid infiltrations in the muscle-tissue of the masseter, quad- 
riceps, deltoid, and diaphragm, but not in the psoas. The biceps muscle 
showed degeneration, local lack of cross-striation, and marked increase 
of nuclei. The thymus-like fragment contained no true thymus tissue; 
the thymus was thus absent. The liver-parenchyma is definitely fatty. 
[Leonard J. Kidd, London, England.] 



VISCERAL NEUROLOGY 127 

Marie, Bouttier and Bertrand. Progressive Myasthenia. [Annates 

de Med., 1920, 10, No. 3.] 

Here the postmortem findings are given from a myasthenia gravis 
case which had been treated for some time advantageously by suprarenal 
extracts. The nervous system was found apparently intact; the classic 
picture of bulbospinal myasthenia without any appreciable lesions in the 
bulbar nuclei. Small lymphoid nodules were scattered throughout the 
suprarenals and the muscles, which the author states is evidence as to 
the relation of the adrenals to the disease. The improvement under 
adrenalin had persisted for six months when the woman died in a few 
days after the onset of pulmonary edema [excess of vagotonia. — Ed.] 

Brun, R. The Origin and Symptomatology of Lumbago. [Schweiz. 

Arch. f. Neurol, u. Psychiat, 1920, 7, 63.] 

Brun emphasizes that we have little accurate knowledge of the causes 
or nature of lumbago. At present, and largely on theoretical grounds, 
three clinical forms are recognized. 

(1) A myogenic form in which the muscle is regarded as the 
primary seat of the disease. Rheumatism and trauma are generally 
regarded as the factors responsible for this form. Workmen who work 
half-stripped and subsequently become chilled acquire a rheumatic affec- 
tion which remains latent until some strain to the lumbar muscles 
unmasks the condition by the sudden appearance of pain. (Primary 
rheumatic origin of traumatic lumbago.) Another view is that strain 
may make the lumbar muscles a " locus minoris resistentiae " upon 
which a subsequent rheumatic affection fastens. The importance of 
actual injury to the muscles, such as tearing, bruising, or haemorrhage, 
as factors in the production of lumbago is generally deprecated. 

(2) Osteo- or arthro-genic forms. Torsion at the lumbar spinal 
joints has been suggested as a cause, but is probably exceedingly rare. 

(3) Neurogenic form. Lumbago has been described as a true neu- 
ralgia of the lumbar nerves, as a toxic neuritis, or as due to injury of 
these nerves. 

In the second section of the paper, Brun analyses twelve personally 
observed chronic cases of lumbago, all of which presented objective 
physical signs. From the study of these he finds that trivial iniuries may 
give rise to severe lumbar pain (" Lumbalgie ") of long duration, and 
that these cases are more numerous than is commonly believed ; that care- 
ful clinical examination reveals in the majority of such cases definite ob- 
jective physical signs in the affected region ; these physical signs include 
unilateral changes in the lumbar and sacral portions of erector spinae — 
wasting, hardening, tenderness to pressure, changes of electrical excita- 
bility such as diminished faradic response and qualitatively altered gal- 
vanic response, and in two instances the presence of transverse furrows 
in the muscle due to localized spasm. 



128 CURRENT LITERATURE 

There were also symptoms referable to the lumbar vertebrae, such 
as tenderness on pressure over the spines, scoliosis convex to the nor- 
mal side in three out of four observed cases, and also reflex rigidity of 
the lumbar spine from pain. Finally, nerve-root symptoms were fre- 
quently observed; pain and sensory loss in the distribution of the pos- 
terior cutaneous branches of the lumbar and sacral nerves and of the 
ilio-inguinal nerve, and pain along the distribution of the sciatic nerve. 
The pain and cutaneous hyper-aesthesian in the lumbar region he 
attributes to this nerve irritation. From these observations he con- 
cludes that chronic lumbago is essentially a perineuritis and neuritis of 
the posterior cutaneous branches of the lumbar nerves, usually of trau- 
matic origin, and but rarely toxi-infective. The sciatic nerve may be 
secondarily involved. The condition is frequently complicated by neu- 
rotic symptoms. [F. M. Walshe in Medical Science.] 

2. ENDOCRINOPATHIES. 

O'Day, J. C. Toxic Goitre. [N. Y. Med. JX, cxi., 1920, p. 6 et seq.] 

In his chapter on toxic goitre O'Day will not admit the existence of 
a pathological secretion. Toxic goitre is toxic because of an over 
secretion of the gland's normal product. 

He objects to the term Exophthalmic Goitre. He complains that 
text-book descriptions of the disease leave the impression that it is called 
exophthalmic goitre because the exophthalmus is a constant symptom. 
To quote, " It is no more exophthalmic goitre than it is death-dealing 
goitre for just as it may result in death may it also result in an 
exophthalmus." 

Toxic goitre he found to be unlike all other varieties. The differ- 
ence, both microscopically and macroscopically, was constant in several 
hundred specimens examined — that difference depended entirely upon 
a preponderance of the acini — "a preponderance that admits of little 
or no intervening stroma." 

He holds the belief that because of this the gland is inevitably over- 
secretive and with so many follicles at work at and during the same 
time he conceives the idea that proper adulteration is prevented. 

This is the way he puts it: "The secretion is thinner, being desti- 
tute of those albuminous elements which govern the consistency of that 
from the normal gland, and, according to the splendid work of Kendal 
at the Mayo Clinic, contains more thyroxin. We come to regard it as 
more volatile, more pungent, and more penetrating. It might be argued 
that the product of a toxic goitre differs so much in these particulars 
from that of the normal gland that its toxicity depends on the difference. 
It is not unreasonable to suppose that because of its volatile and pene- 
trating character it is carried away much more rapidly by the lym- 
phatics, but this is not found to be so. We are convinced that the whole 
trouble results from the actual hyperactivity where every acini has been 



VISCERAL NEUROLOGY 129 

put under a rapid fire too great to permit of the usual admixture of such 
amounts of albumin and globulin as are necessary in establishing the 
normal consistency of the finished product." 

Not satisfied with the end results of his own work on goitre of this 
group,- he reviews the world's literature on the subject in hope of find- 
ing means of establishing some definite cause. His closing paragraph 
bespeaks his disappointment — he says : " The cause of toxic goitre 
is not known, nor is it known that the whole cause had to do with the 
thyroid gland. 

" Experience, however, assures us that lobectomy is the treatment 
capable of the best results, but to attain these results early operation 
should be regarded as imperative." [Author's Abstract.] 

Brooks, H. Physiologic Hyperthyroidism. [Endocrinology, March, 
1920.] 

Brooks points out that a condition may exist under which symptoms 
of thyroid disturbance appear, symptoms mistakenly regarded as indicat- 
ing serious and permanent disease, and that in such cases treatment 
should not be directed to prevent or circumvent these efforts on the part 
of the gland, but to direct or guide nature's efforts. It is unwise to 
attempt measures, and particularly radical measures, which inflict 
changes or limitations of a permanent character on the gland. There 
are many conditions which, particularly in youth, are met only by an 
active secretion on the part of the thyroid; in fact, very many of the 
so-called youthful characteristics are really manifestations of thyroid 
activity. The tachycardia of the pronounced hyperthyroid patient is 
represented in the ' physiologic hyperthyroidism stage by palpita- 
tion. The physiologic demand for an increased thyroid secretion is 
often met by an increase in the size as well as in the activity of this 
gland, and in most instances this is induced by a hypertrophy or hyper- 
plasia, as well as by a mere hypersecretion of the gland. The large and 
prominent thyroid is typical of the mentality and emotional side of both 
boy and girl toward the development of sex characters and full maturity. 
The more charming the young woman, the more virile and attractive 
the youth, the more constantly will it be found that a large gland is 
present and the more certainly will it be noted that, under normal con- 
ditions, such a person responds to emotional and mental stimuli with a 
quick, aggressive and appropriate reaction. Still another physiologic 
evidence of thyroid activity or over-activity in the youth is an increased 
demand and utilization of food. Again at this time, artistic perceptions 
are most keen. All these traits are dependent, at least to a considerable 
extent, on a certain degree of thyroid flexibility and over-activity. 
Periods of great emotional output are accompanied by enlargements, 
though perhaps temporary, of the thyroid. The tremor, characteristic 
of both the hyperthyroid and the enthusiast, may be present, and even 



130 CURRENT LITERATURE 

exophthalmus may become evident or accentuated. Surgical or other 
medical treatment is not indicated. Failure to comprehend and cor- 
rectly manage these cases leads to exophthalmic goitre, neurasthenia or 
eventually nervous and physical inadequacy. [J. A. M. A.] 

Verger, H. Myxedematoid Pains in the Legs. [Journal de Med. de 
Bordeaux, September 25, 1920. J. A. M. A.]. 

Verger refers to pains accompanying changes in the skin suggesting 
myxedema. Both are inclined to be chronic, the pains in leg, knee or 
thigh coming on during walking and standing, but sometimes also during 
repose, but they are never paroxysmal. Rheumatism or internal varices 
is the usual diagnosis; analgesics by the mouth have little or no effect. 
Rubbing aggravates the pains, the elastic stockings cannot be borne. The 
pains are usually bilateral but may suggest sciatica on one side. There 
is tenderness on the back of the thigh, at the bend of the knee and at 
the ankle, and Lasegue's sign is positive. The skin and subcutaneous 
tissue are the seat of the pain, not the path of the nerve. The patients 
have always been females, and the pain on squeezing a fold in the skin 
differentiates the type. The differential diagnosis is confirmed by the 
success of endocrine therapy, especially thyroid treatment. It has to be 
long and persevering, but the benefit from it far surpasses that from any 
other treatment tried to date. Among his patients was one woman of 
45 with this left pseudosciatica and pronounced myxedematous state 
which had developed six months before. No benefit was apparent under 
thyroid treatment until after seven months, but in five months more 
she was completely cured. He gives it for twenty days each month. 

Baar, H. Macrogenitosomia Praecox. [Zeitschrift fur Kinderheil- 

kunde, 1920, 27, Nos. 3-4.] 

This interesting case history of a girl of 3 who was 8 inches taller 
than other children of her age and the external genital organs were 
unusually large, and covered with hair. She had an epithelial cancer of 
the left suprarenal. The author reports this as the twentieth case of 
suprarenal tumor with macrogenitosomia praecox confirmed by necropsy. 
There were only three boys in the list. In Baar's case there was a slight 
cerebellar ataxia, which with the exceptional size of the external geni- 
tals and her general precocious development, suggested pineal gland 
involvement. All previous known cases were in males. Baar compares 
this case with the literature on pathology of the pineal gland. 

Businco, A. Cystic Neuroglioma of Pineal Gland. [Tumori, 

August 31, 1920.] 

Businco says that the case described is the fourth to be published. 
He cites literature and gives photomicrographs of the growth. It was 
found at necropsy of a woman who had died from pneumonia, and there 



VISCERAL NEUROLOGY 131 

did not seem to have been any pathologic influence or special symptoms 
from the tumor except those from mechanical compression. [T. A. 
M. A.]. 

Borchers, E. Postoperative Tetany and Parathyroid Grafts. 
[Zentrablatt fur Chirurgie, March 27, 1920.] 

The operation of grafting parathyroids in postoperative tetany has 
frequently been successful. The author adds two more cases to those 
in which parathyroid grafts have been successful. He states that it is 
unfortunate that ten years ago many surgeons, on the basis of animal 
experimentation, reached the conclusion that the transplantation of 
parathyroid glands from one person to another in treatment of tetany 
was useless. Many authors had shown by animal experiments that the 
transplanted glands would not preserve their structure and function, but 
in man the glands, as can now be shown by a whole series of cases 
extending over several years, do preserve their structure and function, 
or at least a structure and function that protects. Animals behave func- 
tionally different from humans, which laboratory zealots must learn. 

Brown, A., MacLachlan, I. F., Simpson, R. Calcium in Tetany. 
[Am. Journ. of Diseases of Child, June, 1920. J. A. M. A.]. 

Constitutional reactions were produced following intravenous injec- 
tion of calcium lactate in 1.25 gm. doses in nine patients observed by 
Byfield and his associates. The degree of reaction varied from a slight 
drowsiness to almost complete collapse accompanied by dyspnea. The 
signs of reaction disappeared usually between one and seven hours; the 
more severe the reaction the longer it took the patient to recover. A 
temporary absence of both electrical and mechanical signs of tetany, 
usually lasting from seven to ten hours was noted. Apparently no bene- 
ficial therapeutic effect was exerted, unless this was supplemented by 
the administration of cod liver oil and phosphorus, and in this instance 
the reduction of the tetanoid symptoms is a little more rapid than with 
the employment of cod liver oil and phosphorus alone. Cod liver oil and 
phosphorus produced an increase in the blood calcium with a correspond- 
ing reduction in the mechanical and electrical signs, within a period of 
from ten to seventeen days. 

Stheeman, H. A., and Arntzenins, A. K. W. Signs of Calcium 
Deficit. [Neder. Tijdschrift, March 27, 1920, 1 No. 13. J. A. 
M. A.]. 

Stheeman is chief of the children's hospital at 's Gravenhage and his 
long and extensive experience has convinced him that a large number of 
pathologic conditions have the one feature in common of an inadequate 
reserve of calcium. This calcipriva stigma is the underlying cause 
responsible for spasmophilia, for the habitus asthenicus, universal asthe- 



132 CURRENT LITERATURE 

nia and allied conditions. That this fact has not been fully appreciated 
before is due to the lack of a simple and reliable quantitative test for the 
calcium content of the blood. Wright's method reveals only the calcium 
that is dissolved, and there is no standard for camparison between the 
findings by different workers. The DeWaard method of microtitration 
with one-hundredth normal solution of potassium permanganate gives 
reliable findings with as little as 0.5 or 1 c.c. of blood or serum. The 
findings in the blood serum of thirty-five sick children and in a number 
of healthy children and a few sick and healthy adults are tabulated. In 
the fifty-eight healthy children the calcium content was constantly 
between 12 and 13 mg. per 100 c.c. of serum. In the others it ranged 
from 8.25 to 17 mg. The age does not seem to influence the calcium 
content, but an extremely low figure was found in the prerachitic con- 
dition, with intestinal infantilism, neuroses of the vegetative nervous 
system, universal asthenia, and tuberculosis. The severity of the patho- 
logic condition was reflected in the lowness of the calcium content, and 
the figure rose as the general condition improved. A further proof of 
his theory is the prompt benefit in all these pathologic conditions when 
treatment aiming to promote retention of calcium, namely, with cod liver 
oil and phosphorus, was systematically given. To estimate the improve- 
ment, he does not trust to personal impressions but measures it with 
precision by testing the sensitiveness of the peripheral nerves to the 
galvanic current. This has confirmed that the Erb sign is nearly always 
positive with a low calcium content and is never positive with a high 
content (aside from rachitis). Also that the Erb sign is most pro- 
nounced, the greater the deficit in calcium, and that as the Erb sign 
becomes less pronounced, the calcium content is also found to be increas- 
ing. It seems thus beyond question, he concludes, that the cause is a 
local calciprivic condition of the nerve tissue, at least in the peripheral 
neuron, as a part of a general deficit of calcium in the tissues. It con- 
forms to Quest's and McCallum's findings in dogs, and to the Chvostek 
sign in children. The latter he regards as a more sensitive sign than 
the Erb reaction. 

Rossi, S. C. Influenza, Suprarenal Insufficiency and Manic- 
Depressive Psychoses. [Anales de la Faculad de Med., Montevi- 
deo, December, 1919, 4 No. 12.] 

It has been observed not infrequently that psychoses of a depressive 
type develop after influenza. Rossi has encountered nine such cases 
in which a diagnosis of manic-depressive psychosis was made. He 
ascribes it to the suprarenal insufficiency which was manifest. This 
assumption was confirmed by evidences of suprarenal insufficiency in six 
other patients with manic-depressive psychoses who had not had influ- 
enza. It was placed on a still more solid basis by the efficacy of supra- 
renal treatment. He is optimistic about the use of epinephrin, but 



VISCERAL NEUROLOGY 133 

apparently is unaware of its almost total failure in pronounced manic- 
depressive psychoses as reported by others. 

Bruening. Removal of Suprarenal Capsules for Epilepsy. [Zen- 

tralbl. f. Chir., October, 1920.] 

The removal of the suprarenal capsule has been shown to diminish 
susceptibility to convulsions and reduces muscle tonus. Fischer, who 
has extensively experimented, believes that the somatic nervous system 
plays only a subsidiary role in epilepsy, the vegetative nervous system 
being of prime importance. This would explain the ill-success which 
has attended operations on the brain. Bruening, with Fischer's work 
in his mind, has applied the principles to man and has excised the left 
suprarenal capsule from nine patients suffering from epilepsy. He 
describes the technique in some detail. The organ is approached by the 
abdominal route. The left adrenal is that chosen because, although the 
right lies lower, there is danger of wounding the biliary passages or 
tearing the liver. Bruening makes for the lower border of the pan- 
creatic tail after pulling the colon well down and perhaps mobilizing 
the splenic flexure. The kidney is depressed and the fatty capsule dis- 
sected from the suprarenal, which is removed after picking up its 
vessels. Drainage is only instituted if halemostasis has not been satis- 
factory. All the patients recovered from the operation. The dissec- 
tion is a deep one, and long instruments are necessary. In two cases, 
where fits were a daily occurrence, there have been no further convul- 
sions. In all the others there was improvement, sometimes a very great 
improvement. Bruening is encouraged by this method of treatment. 
The cases were unselected, and one at least (an old encephalitis) was 
unsuitable for operation. He believes that the best time for interference 
is after puberty, when growth is finally slowing down. His two suc- 
cesses were in patients aged respectively 18 and 21 years. He admits 
that this question of the influence of the sympathetic system on the 
brain is in its infancy, and contemplates the necessity for removal of 
the right suprarenal as well. Accessory adrenals and compensatory 
hypertrophy of the remaining adrenal tissue are possible causes of 
failure which require investigation. 

Gavazzeni, S. Two Cases of Pituitary Tumor with Acromegalic 
Syndrome Cured by X-rays. [Radiol. Med., 1920.] 

One case had the complete clinical picture of acromegaly, and radio- 
graphically showed evidence of pituitary tumor. The symptoms of dis- 
ease were of four years' standing, but the condition improved very 
much under X-ray treatment. The other case showed the same symp- 
toms and signs in a milder degree, and the results of radiotherapy were 
equally good. 



134 CURRENT LITERATURE 

Reichmann, V. Pituitary Tumors. [Deut. Archiv. fur Klin. Med. 

September 26, 1919.] 

Reichmann reports two cases' in which the symptoms had suggested 
exophthalmic goiter, tendency to acromegaly, suprarenal disease, and 
disease of the genital glands, but necropsy revealed in the woman of 36 
an eosinophil adenoma in the pituitary, and in the man of 51 the roent- 
gen findings seem to indicate a similar tumor. The face was red and 
puffy in both; the exophthalmos was pronounced but the thyroid was 
not enlarged, and the pulse was slow, with extreme weakness of muscles, 
emaciation, edema of the legs, slight glycosuria, no albuminuria, and no 
signs of contracted kidney, but the blood pressure was very high, and 
there was pronounced osteoporosis of the spine. The symptoms thus 
indicated excessive functioning of the pituitary and suprarenals, with 
thyroid deficiency. The curvature of the spine from the osteoporosis 
was evidently responsible for the severe neuralgiform pains in the back 
in the woman's case. Tests for epinephrin in her blood were negative, 
but the blood pressure of 200 mm. mercury pointed to the suprarenals, 
and as the pains in the back were unbearable, Reichmann yielded to the 
patient's demand for operative relief, and removed the left suprarenal. 
The woman died nine days later from peritonitis, nearly three years 
from the first onset of symptoms, which had been edema of the legs, 
exophthalmos and arrest of menstruation. The latter had never been 
constantly regular. [J. A. M. A.]. 

Jaugeas. New Contribution to the Radiotherapy of Pituitary 

Tumors [Jourl. de radiol. et d'electrol, 1919.] 

Xo affection enables one to judge of the deep action of X-rays, to 
control their efficacy, and to appreciate the value of technique better 
than the above-mentioned, thanks to the measurable variations in the 
patient's field of vision. The author quotes observations on a woman of 
25 presenting the classic symptoms of pituitary tumor with acromegaly. 
Radiography of the skull showed almost entire destruction of the sella 
turcica, a breaking-up of the floor of the cavity with opening of the 
sphenoidal sinuses. Disorder of vision first attracted her attention; an 
oculist advised recourse to radiotherapy. Twenty seances produced a 
very marked improvement in the condition of the sight. Examination 
of the visual region showed a temporal hemianopsia on the left side and a 
hemianopsic scotoma on the right. Radiotherapy was continued two 
years, employing two temporal and two frontal portals of entry for the 
rays, each of which received 50 H. every fortnight of a penetrating 
irradiation, filtered at first by 2 mm., then by 4 mm. aluminum. Improve- 
ment began from the first months of treatment. The scotoma disap- 
peared; the two visual regions extended; visual acuity improved and 
became nearly normal. At the same time the general condition of the 
patient improved and she soon regained her intellectual activity. The 



/ ISCERAL NEUROLOGY 135 

improvement obtained might be considered as nothing more than an 
immediate and temporary effect of the radiotherapy, were it not that an 
older observation, in which the beneficent effect lasted for six years, 
permits one in this case to speak of a cure. Treatment should always 
be begun early, when the syndrome of glandular hyperactivity is mani- 
festing itself. It should be conducted with care, so as to preserve a 
sufficient functional value of the gland and to avoid production of a 
syndrome of insufficiency in place of that of hyperactivity, such as 
occurs in exophthalmic goiter. The visual field should serve as guide 
during progress of treatment. [Medical Science.] 

A. Priesel. Hypophyseal Dwarfism. [Ziegler's Beitr., Bd. 67, H. 2, 
1920.] 

According to Hansemann's rather formal classification the propor- 
tionate dwarfs are to be separated in primordial and infantile ones. From 
those who belong to the infantile type only a few show alterations of 
the pituitary body; so pituitary nanosomnia is a destructive result of 
glandular part of the pituitary by tumors or some other pathological 
proceedings occurring before completed lengthgrowths of the body. 

The author's case was a man, 91 years old, who died of lobular 
pneumonia, measured only 132 cm, but without manifesting any dispro- 
portiohalities and had stopped growing with 15 years. He never gave 
evidence of any pathological mental trouble, but was beardless and 
showed no hairgrowth in axillary and genital region. General obesity, 
external genitals small. The skeleton bones were developed like those 
of adults (well marked and characteristic plastic bone-surface); united 
epiphyses. The trouble in growth seemed to have been the result from 
some anomaly in the development of the pituitary body. The neuro- 
hypophysis was found outside the sella turcica beneath the tuber cine- 
reum and was communicating with the glandular part only by a tissue- 
band from 0.5 mm. The parenchym of the anterior lobe was lining as a 
thin membranous stratum the sella turcica and also a cavernous space 
from hazelnut size in the sphenoid, which largely communicated with 
the bottom of the sella and had no connection with the sinus sphenoidalis 
itself. A canalis craniopharyngeus was leading vertically through the 
cranium from the ground of the mentioned cavern and was appearing 
behind the vomer. Histologically the nervous part of pituitary was found 
without any alterations, while the glandular tissue, compressed as men- 
tioned to 0.2 mm., was atrophic and showed only ungranulated cells, 
being in its whole extent not even so large as the pituitary of a child 
of 15 years. 

The cause of the anomaly seemed to have been an ossification trouble 
of the sphenoid, perhaps through persistence of the canalis cranio- 
pharyngeus. The extent lost of glandular parenchym is probably con- 
nected with perturbed blood circulation brought up by the abnormal rari- 



136 CURRENT LITERATURE 

fication of the continuity between both parts of the gland. The trans- 
position of the neurohypophysis beneath the tuber cinereum might be 
regarded as an autonomous anomaly without any other trouble in the 
development that could be proved in a second case of the author. 

The parathyroids showed hyperplastic alterations which were hitherto 
not yet seen associated with nanosomia, the more no sign of osteomalacia 
could be found. The thyroid gland was senile, atrophic, the adrenals 
rather reduced in size. The testes, also atrophic, Leydig's cells were 
not to be found. The atrophy of germinal glands probably occurred in 
an early time of age, brought up by disfunction of the pituitary and 
being the cause of eunuchised fat-disposition. 

The alteration of the pituitary body, the stopping of growth at 15 
years, and the infantile proportions of the skeleton bones, yet the epi- 
physes were all united, are proof that the case is belonging to the type 
of infantile nanosomia. Basing on the anatomical substratum of the 
case, the author is glad to admit that the atrophy of glandular part of 
pituitary gland only gradually took place, by which probably at first 
only the cartilaginous growths were stopped ; meanwhile the further ossi- 
fication was going on regularly, leading to the uniting of epiphyses. 
[Author's Abstract.] 

Barthlemy, R. Inherited Syphilis of the Endocrine System. 

[These, Paris, 1919.] 

The heredosyphilitic septicemia (intra-uterine or not) reaches the 
endocrine system as well as the other organs. Pathologic anatomy and 
histology prove it. Clinically, the Wassermann reaction and the results 
of the antisyphilitic treatment, associated or not with ortherapy, confirm 
it, chiefly in the pluriglandular syndromes where the attack is rather 
superficial, fragmentary and curable. 

But apart from this, certain endocrine manifestations are bony, den- 
tal, and trophic troubles which we find precisely again in the dystrophic 
inherited syphilis (gigantism, dwarfishism, infantilism, etc.) It seems 
that these consequences could be averted by sufficiently precocious 
treatment. 

Other troubles, athrepsy, weakness (Dr. A. Fournier) often come 
from a touch, at least histologic, of the endocrine organs. Lastly, 
there exist phenomena still more delicate. Why do so many heredo- 
syphilitics become chlorotic at puberty? Why did Pel's patient become 
acromegalic in consequence of a traumatism of the skull ? Why do cer- 
tain heredosyphilitics die or present a glandular syndrom in consequence 
of a very slight infection which does not ordinarily attack a normal 
organism? 

Here is found a biopathologic susceptibility of the glands, which 
produces an unstable balance which will prove fatal under the influence 
of a cause that would not even affect an ordinary person. In these 



VISCERAL NEUROLOGY 137 

cases treatment may be efficacious. Similar cases may be seen among 
the heredosyphilitics of the third generation; sometimes it is the cause 
of certain mental troubles (instability of character, inattention, etc.) 
With these very often the specific treatment does not act. This is the 
reason why some try to explain these facts by a toxemic inherited 
syphilis. In reality this gives less transmission of a syphilitic toxine 
than transmission of a bad glandular function; for these, opotherapy 
may be efficacious. For example: If a grandson does not inherit the 
treponema at least he does the endocrine lesion or the trouble of secre- 
tion. (Similar heritance *of j»n exopthalmic Wen.) Maranon has seen 
analogous facts outside of syphilitics. Then, all degrees exist, from the 
massive and mortal lesions where swarms the treponem to the purely 
secretory insufficiencies which may long remain latent. So is explained 
the origin of heredosyphilitic dystrophies, when the trephonemea does 
not act by itself and locally there exist among the children of heredo- 
syphilitics troubles which the antisyphilitic treatment is powerless to cor- 
rect. Here the inheritance is not the syphilitic but the glandular insuffi- 
ciency that may effect all descendants. The first conditions are helped 
by all the above means, the second by opotherapy, but even this is power- 
less upon the definite dystrophic. [Author's Abstract.] 

II. SOMATIC SENSORI-MOTOR NEUROLOGY. 
4. MID BRAIN-CEREBELLUM. 
Durand. Encephalitis Lethargica. [Riforma Med. 1920.] 

The bacterioscopic and ultra-microscopic examinations of blood and 
cerebrospinaal fluid from cases of lethargic encephalitis were constantly 
attended by negative results. Subcutaneous and intravenous inocula- 
tions of blood and cerebrospinal fluid into rabbits, guinea-pigs, and white 
mice were also entirely unsuccessful. Culture from the cerebrospinal 
fluid remained sterile. Bouillon culture from the blood of four out of 
six different cases allowed the author to isolate a very small Gram- 
positive coccus, of which he describes the biological properties, without, 
however, considering it as the specific agent of the malady. This 
because, in severe disease of infectious origin, the blood may be invaded 
either by the specific germ localized before in a certain organ, or by 
other germs merely complicating the morbid process without being 
directly connected with its causation. 

Roger, Henri. Acute Epidemic Encephalitis: The Lethargic, 

Myoclonic, Choreo-Ataxic, Delirious and Neuralgic Types. 

[Marseilles Medical, April 15, May 1, and June 15, 1920.] 

This paper, read at the meetings in February and April, 1920, of the 

Comite Medical des Bouches-du-Rhone, gives a review of the French 

and foreign work on epidemic encephalitis up to this time, and also 



138 CURRENT LITERATURE 

gives the author's view of several of the points, as well as detailed per- 
sonal observations in fifteen new cases. The classical symptoms of the 
lethargic form are described briefly, with emphasis on the " negative 
symptoms," absence of clinical signs relating to the meninges, and nega- 
tive laboratory findings, blood culture, Wassermann, etc. He takes excep- 
tion to the opinion prevalent at that time that there is no cytological 
or chemical meningeal reaction, and calls attention to two signs which 
are so constant as to be almost pathognomonic: the parkinsonian syn- 
drome (mask-like facial expression, cataleptoid attitudes and tremors 
continuing with the limbs at rest), and paralysis of the ocular accomo- 
dation. This is often present in the early stage, and is usually persistent. 
The other types of epidemic encephalitis fall into four groups: 
i. The myoclonic type, characterized by pain and sudden muscular 
spasms. Hence Roger suggests calling this type algo-myoclonic. This 
form may be local or general (affecting the abdomen and diaphragm, as 
in epidemic hiccough). In a previous communication (Le Journal des 
Praticiens, May 8 and 15, 1920), Roger has given a detailed description 
of this type. In the present paper he reports interesting cases seen at 
Salonika ambulatory at the onset, in which the salient features were 
paralysis of the median and ulnar nerves, perpura of the upper extremi- 
ties, and grave constitutional disturbances. 

2. The chore o-ataxic type, in which the contractions are less abrupt, 
but lasting longer than in the myoclonic type, and are accompanied by 
insomnia and delirium. He mentions one severe case attacking a patient 
15 years of age, and proving fatal in four days. 

3. The delirious type. These cases were referred to the psychopathic 
ward. 

4. The neuralgic type. 

Roger insists that all these types have an identical causation. The 
two most frequent forms, the oculo-lethargic and the algo-myoclonic — 
in their pure forms the exact opposite of one another — present enough 
facts, anatomical-pathological, semiological, or symptoms apparently of 
the other type appearing during the course of the disease, to confirm 
this theory of their common origin. Roger reports cases of pure lethar- 
gic encephalitis ushered in by myoclonic spasms during the period of 
somnolence, other cases with localized myoclonic sequellae, and some 
cases with algo-myoclonic syndrome preceding the typical lethargic 
encephalitis. 

While insisting upon the polymorphism of epidemic encephalitis, 
Roger attempts, in order to clarify the picture of its multiple clinical 
types, a classification based upon the particular functions of the nervous 
system involved, and to distinguish in each group those functional dis- 
turbances due to hyper, or hypoactivity, or to derangement of function, 
as hyper, hypo and para. 



SOMATIC SENSORI-MOTOR NEUROLOGY 139 

1. Motor form. Hyper: myoclonic, choro-ataxic, choreic, tetanic 
and convulsive. Hypo: paralytic, paraplegic and polyneuritic. Para: 
Parkinson type. 

2. Sensory form. Hyperalgic form. 

3. Psychic form. Hyperdelirious, mental. Hypo: mental depres- 
sion. 

4. Affecting the sleep function. Hyper: somnolence. Hypo: in- 
somnia. 

The pathology is extensively considered. The hypothesis of the non- 
specific origin of encephalitis is discarded, as he cannot agree with 
those writers who consider encephalitis a syndrome affecting various 
portions of the central nervous system — usually the peduncle — but due 
to divers causes, either infections, as tuberculosis, syphilis, influenza, 
poliomyelitis, or intoxications, as botulism. Encephalitis may of course 
occur in syphilis, without any causal relation between the two diseases, 
as in two cases which he reports with negative Wasserman of the blood 
and spinal fluids. The influenzal origin of encephalitis is accepted by 
some writers on the ground that epidemics of influenza and encephalitis 
occur close together, as in 1889 and 1890, and that the respiratory 
organs are rarely involved, but Roger does not hold this view. The 
difference in the clinical characteristics of influenza affecting the ner- 
vous system and encephalitis, in their anatomical lesions, and in their 
mode of transmission lead Roger to regard them as two distinct infec- 
tions. He also believes that encephalitis is due to some specific organ- 
ism and bases this upon (1) the anatomical lesions, which he discusses 
with special reference to the histological type, and to their sites; (2) the 
epidemiological and etiological facts known, and to the (3) experimental 
researches of American and French authors concerning the virus. 

Roger, then, believes that the morphology of epidemic encephalitis is 
due, not to any variations in the virus, but to predominance of the lesions 
in certain sections of the mesocephalus or the neuraxis producing the 
various clinical types, the oculo-lethargic, choreic or the parkinsonian 
syndrome. He does not deny the possible myelitic origin of certain 
myoclonic movements, but he describes certain features of alternate 
hemimyoclonia which favor the bulbo-protuberal origin of the algo-myo- 
clonic syndrome. [Author's Abstract.] 

Sala, G. Histo-Pathological Observations on the Ciliary Gang- 
lion in Cases of Lethargic Encephalitis [Boll d. Soc. Med- 
chir. di Pavia., 1920, 33, 93.] 

Investigations were made by Cajal's reduced silver method on the 
ciliary ganglion from cases of lethargic encephalitis which had presented 
during life various pupillary troubles. Some ganglion cells no longer 
showed their characteristic structure and appeared transformed into an 



140 CURRENT LITERATURE 

irregular protoplasmic mass containing many small and roundish bodies 
stained black by the reduced silver. The author puts forward the sug- 
gestion that they may be granules of pigment but with characters some- 
what different from those one finds in normal spinal and sympathetic 
ganglion-cells. Sala's observations remind one very much of the pig- 
ment-like granules described by Da Fano and Ingleby (Proc. R. Soc. 
Med., 1919, 12, [Sect, of Path.], 42), also in cases of lethargic enceph- 
alitis and in places of the central nervous system where brown or black 
pigment does not generally occur. [Medical Science.] 

Bramwell, E. Lethargic Encephalitis. [Lancet, May 22, 1920, 1, 

No. 5047. J. A. M. A.] 

The material forming the basis of the pathologic inquiry made by 
Bramwell consisted of five fatal cases. He found (1) hemorrhage rare; 
(2) edema of the nerve tissue; (3) proliferation of neuroglia, and (4) 
infiltration of nerve tissue and perivascular lymph sheath with cells, 
usually lymphocytelike in type. These changes were seen most strik- 
ingly in the ventral portion of the pons, especially in the region of the 
substantia nigra, implicating the fibers of the third nerve as they pass 
out, and thus accounting for one of the common symptoms of the dis- 
ease. In no case were any organisms, or bodies suggesting organisms, 
seen. 

Claude, H. Myotonic Form of Lethargic Encephalitis. [Bull, et 
Mem. Soc. Med. des Hop. de Paris, March 4, 1920.] 

Three cases of a myotonic form of lethargic encephalitis are here 
recorded in which the patients showed changes of muscular tonus inde- 
pendently of any involvement of the pyramidal system. In two cases 
the physiognomy was absolutely expressionless, although somnolence 
was not a pronounced feature. On attempting to move the limbs con- 
siderable muscular rigidity was encountered. One of the patients 
resembled a case of paralysis agitans owing to his mask-like expression, 
muscular rigidity, and tremor of the hands. Claude suggests that the 
peculiar appearance presented by the patients was due to changes in the 
locus niger. 

Netter, A. Treatment of Epidemic Encephalitis. [Bui. de l'Acade- 
mie de Med., March 30, 1920, 83, No. 13.] 

Netter comments on the analogy between this disease and epidemic 
poliomyelitis, although they are separate entities. Treatment along the 
same lines is indicated for both, that is, intraspinal injection of con- 
valescents' serum for its specific, and hexamethylenamin for its general 
bactericidal action, with' a fixation abscess to reenforce the natural defen- 
sive forces. However, he says, the time has not come yet for intra- 
spinal serotherapy as the presence in the blood of antibodies neutralizing 



SOMATIC SENSORI-MOTOR NEUROLOGY 141 

the virus has not yet been demonstrated with the encephalitis, as it has 
been demonstrated for poliomyelitis. Another reason is that the virus 
is in the nerve centers only for a brief period in poliomyelitis, while this 
may keep up for three months in the epidemic encephalitis, and we do 
not know how early it appears in the blood in the latter. He gives the 
hexamethylenamin by the mouth in fractioned doses in treatment of all 
meningitic conditions and poliomyelitis, and commends it for epidemic 
encephalitis although not absolutely certain of its efficacy as yet. He 
knows of a case in which arsphenamin treatment was tried with disas- 
trous effect. On the other hand, jaborandi or pilocarpin seems to aid by 
promoting elimination of the virus through the saliva as in rabies; in 4 
of his 72 cases the salivary glands were swollen, and exaggerated sali- 
vation was manifest in a number of others. He gives epinephrin with 
the jaborandi to counteract its depressing effect. In the 27 patients 
treated with injection of 1 c.c. of turpentine, an abscess developed in 
19 and all these recovered except one pregnant woman. In 13 of the 
cases the condition was so grave that hope had been abandoned. In 14 
of the 19 cases reacting with abscess production, the encephalitis was of 
the myoclonia type. In 25 grave cases in which no attempt had been 
made to induce the fixation abscess, more than 50 per cent. died. Hip- 
pocrates noted that those who escaped the " lethargus " were generally 
those who had developed a suppurative process, and when Fochier 
applied the turpentine abscess as a therapeutic measure, he explained its 
efficacy by its attracting the virus to the spot. Netter ascribes it to a 
stimulating action on the organs which provide the natural means of 
defense; myelocytes appear in the blood, demonstrating the participation 
of the bone marrow. It is probably, he remarks, by a similar mechan- 
ism, that vaccines, serums and nucleinates exert their action. Another 
patient with extremely grave epidemic encephalitis recovered after the 
development of a spontaneous deep abscess in the buttock. [J. A. M. A.] 

Bastai, P. On the Aetiology of Lethargic Encephalitis. [Gazz. 
d. osp., 1920.] 

The author, after having briefly reviewed the opinion expressed by 
other investigators on the aetiology of encephalitis lethargica, puts for- 
ward the suggestion that its different clinical forms may be due to the 
presence in the tissues of various germs of different pathogenic power, 
perhaps associated with an as yet unknown specific virus. 

Tron, G. Lethargic Encephalitis: Its Possible Relation with 
Mixed Infections. [Gazz. d. osp., 1920.] 

Summary of a communication made at the " Accademia Medico-Fisica 
di Firenze," April, 1920. Seven rats were inoculated intraspinally with 
the filtered emulsion of three human brains from typical cases of lethar- 
gic encephalitis. The animals soon became affected by a disease chiefly 



142 CURRENT LITERATURE 

characterized by lethargy, from which, however, they recovered in 
about 8 days. At the microscopic examination of the brains small peri- 
vascular haemorrhages and a moderate small-celled infiltration of the 
brain substance were found. The same facts were noticed in the walls 
of the cerebral ventricles, together with a more remarkable lymphocy- 
tosis of the cerebral spinal fluid. From cultures made from the filtered 
emulsions either of human or cat's brain a very small coccus was iso- 
lated. The author, therefore, is of the opinion that the specific agent of 
lethargic encephalitis may belong to the group of filter-passing cocci. 

At the same meeting of the above-mentioned Academy, Pisani and 
Varisco made a communication regarding their isolation from other 
cases of encephalitis of a diplococcus different in certain respects from 
all known diplococci. In the opinion of the authors, however, their 
diplococcus is only a germ frequently associated with the still unknown 
specific agent of the disease. [Medical Science.] 

III. SYMBOLIC NEUROLOGY. 
1. PSYCHOLOGY — NEUROSES — PSYCHONEUROSES. 

Freimark, H. Eroticism and Spiritualism. [Internat. Ztschf. f. 

aertz. Psychoanalyse. Vol. Ill, No. 5.] 

A careful psychoanalytic study of clairvoyancy clearly reveals the 
erotic origin of the manifestations. Following the principle that every 
thought tends to assume a form (James), the medium who is unable to 
give her thoughts form through art embodies them in dream figures. 
The conduct of mediums in their trances is described to show its visible 
resemblance to erotic excitement. In their essential nature the physical 
and intellectual manifestations are identical, only differing in the form 
of expression given them. In confirmation the evidently sexual nature 
of the manifestations in Mesmer's experiments is cited. The view that 
the instinct of reproduction, i. e., the instinct to create tends to phychic 
creation if its physical development be hindered, cannot be given too 
much emphasis, the author avers, and it may be remarked that the talent 
of female artists is found to develop after some resistance, internal or 
external, to the expression of the maternal instinct had been encoun- 
tered. Artistic activity springs from the same source as that of the artist, 
but in the artist it finds expression at a higher level. For both direc- 
tion and concentration of energy are important. The medium is able 
to divert the energy which would otherwise pass into the organs of the 
body, into the psyche. This form of creation exercises a very great 
influence on the destiny of mankind and to a certain extent each indi- 
vidual is dependent on a similar but less marked development of his own 
psychic aspirations, which become symbolic in some form or other. A 
striking characteristic of mediums is their wish to belong to a higher 
sphere of life than that in which their lot is cast. Their controlling 
spirits bear celebrated names, or appear surrounded by glory, they are 



SYMBOLIC NEUROLOGY 143 

Egyptian or Indian royalties, even deity itself approaches them. The 
medium only represents those aspirations common to all mankind in an 
exaggerated manner. 

In this connection the author refers to the conception of Paracelsus, 
namely, that the world creates us and that we project into the world 
elements of our own, those treasures of hopes, beliefs, and wishes upon 
which the heart hangs. The scientist should not overlook the deep 
shadows from which these faint gleams of light stream forth. His 
endeavor should be to free man from the arbitrary vacillations of the 
unconsciousism, from a subjection to individual dreams and elevate him 
to a realization of the general trend of life revealed in prospective 
tendencies. 

Freud, S. Methods of Psychoanalytic Therapy. [Intern. Zeitschf. 

f. a. Psychoanalyse, V. No. 2.] 

This article is an address delivered at Buda Pesth in September, 
1918, in which Freud gives a summary of the past successes and a fore- 
cast of the future prospects of psychoanalysis. Psychoanalysis, he says, 
has been successful in discovering the unconscious resistances at the 
root of the neuroses, in bringing these fully to consciousness, and, mak- 
ing use of the transference to the physician, in securing normal adjust- 
ments of neurotic conflicts. The name, psychoanalysis, was originally 
used because of the analogy of the process of separating the soul into 
its elements with the chemical process by which material substances are 
separated into their elements. In some quarters the success of this 
process has suggested the possibility of carrying the analogy still fur- 
ther, and the attempt has been made, after the analysis, to build up the 
character in a manner which was supposed to resemble chemical syn- 
thesis. It has been claimed that this is the direction which the future 
development of psychoanalysis must take and the cry was raised that 
there could be too much analysis and not enough synthesis. Such 
attempts at synthesis, says Freud, are as senseless as would the attempt 
to resurrect an animal organism after its destruction by vivisection. 

The future advances of psychoanalysis must be made in an entirely 
different direction, he asserts — in the direction of " active therapy," 
referred to by Ferenczi in his article on the technical difficulties of an 
analysis of hysteria. 

Freud indicates what may be understood by the term " active 
therapy." If the activity of the analyst results in making conscious 
what was repressed and in discovering the resistances, it has already 
been considerable. Further questions, nevertheless, arise: Shall the 
patient be left to battle alone with the resistances laid bare by the 
analysis? Should more specific aid be given him than is contained in 
the encouragement to get well and the transference? Does it devolve 
upon the physician to help the patient to that psychic position which is 



144 CURRENT LITERATURE 

the most favorable for accomplishing the desired result — the allaying 
of the conflict? If the patient's recovery depends on the solution of 
external difficulties is it the province of the physician to so far enter 
into the struggle as to adapt these circumstances to the patient's vic- 
tory? Freud's answer is that activity in aid of the patient is beyond 
all doubt justified, and he adds that the fundamental principle which 
should here guide the physician is that the cure must be carried out as 
far as possible in abstinence on the part of the patient — not total 
abstinence from satisfaction, which would, perhaps, be impossible; not 
abstinence in the popular sense of sexual continence, but abstinence 
of a sort more intimately connected with the dynamics of the disease 
and more important for the cure. It was renunciation which gave rise 
to the disorder and the symptoms are substitutes for satisfaction. For 
complete cure a very strong desire for cure is indispensable. It may 
be that, if the symptoms are too quickly ameliorated, this desire may 
be weakened. Here the physician should interfere to prevent a prema- 
ture diminution of the suffering which is at the root of the wish to be 
restored to health, and if the symptoms disappear too rapidly he should 
create unsatisfied wants in other directions which will give energy to 
the desire for complete health. 

Danger of such premature amelioration of symptoms is threatened 
from two directions. The libido in part set free by the analysis, may 
become engaged in devious substitute satisfactions, in activities which 
perhaps previously existed but which are now endowed with strong 
emotional energy. The patient constantly engaged in these diversions 
is no longer stimulated by the desire to get well. A half-cured patient, 
for example, may enter prematurely into relations with a woman who 
is not adapted to him, with the result that an unhappy marriage is con- 
tracted. It is the physician's duty to prevent such substitute adjust- 
ments, if possible. 

It is harder for him to interfere in situations of the second class, 
namely, where the patient's desire for cure is weakened by reason of the 
transference to the physician. Such a transference is a real hindrance 
to the success of the therapy and should be avoided. Freud says that 
it has been his invariable custom to refuse to make of his patients close 
adherents and followers and to impose on them his ideals. This was 
one of the points which gave rise to the controversy between him and 
the Swiss school, and though at the time he had the impression that 
some of his friends, among them Jones, thought this refusal harsh and 
arbitrary, he is nevertheless convinced that he is in the right. He is 
also unable to accept the suggestion of Putnam that psychoanalysis might 
be offered to the patient as a philosophic viewpoint which would lend 
content and meaning to life and ennoble the character. An expedient 
of this sort, Freud asserts, is only force in disguised form. 

Experience has particularly emphasized the necessity of adapting 
" activity " in the analysis to individual differences in the cases. The 



SYMBOLIC NEUROLOGY 145 

physician would have little success in overcoming phobias if he made 
no attempt to, free the patients from their fears until they voluntarily 
gave them up as a result of the analysis. In this way he would never 
be able to bring the material into the analysis, the discovery of which is 
indispensable for the cure. Taking agoraphobia as an example, he 
states that the patient should be induced to go among people in the 
street — to actually strive against the fear — and in the course of this 
effort the memories and ideas are revived which render the solution 
of the patient's problem possible. Passive waiting seems still less indi- 
cated in severe compulsion neuroses. The tendency of this disease is, 
in general, toward indefinite prolongation of the treatment, as it were 
toward " asymptotic " treatment ; the analysis brings much to con- 
sciousness, but fails in affecting changes. The proper technique is to 
make the desire for cure so strong that it becomes itself a compulsion, 
and then to oppose this compulsion to the pathological one. 

The author offers these cases only as examples of the problems with 
which the analysis is at the present time confronted. In closing his 
address, he expresses the hope that the use of psychotherapy may be 
extended in such manner that the mass of the people, among whom 
psychoneuroses are so prevalent, may be benefited thereby. [C. 
Willard.] 

Jones, E. Anal Erotic Traits of Character. [Internat. Zeitschift. 

f. a. Psychoanalyse, 1919, V. No. 2.] 

In this article, which has appeared in English in the Journal of 
Abnormal Psychology, Vol. XIII, and also in Jones' "Papers on Psy- 
choanalysis," 2d edition, the author gives the following summary : At 
the root of the anal erotic processes is either the tendency to " retain " 
or to " yield," and from each of these is derived a separate series of char- 
acteristics. Every hindrance offered to the tendency predominating in 
the personality is met with opposition leading to deeply stamped charac- 
ter traits in the form of obstinacy, irritability, self-will, and bad temper. 
Characteristics to which both fundamental tendencies contribute are 
tenacity, inadaptability, capacity of concentration, with strivings in the 
direction of thoroughness and perfection. 

In the adult the character traits depend principally on the reciprocal 
relation of the individual attitudes toward the two fundamental phases 
and the degree in which the individual reacts to each in the process of 
development and sublimation. Sublimation may lead, on the one hand, 
to thrift, miserliness, the love of possessing and taking care of things, 
to a capacity for tenderness as long as the person loved is submissive; 
or, on the other, to productivity, prodigality, love of creation, an incli- 
nation to impose the person's own personality on everyone and every- 
thing, a liking for modeling and molding, great pleasure in making pres- 
ents. Reaction forms are orderliness, cleanliness, pedantry and disin- 
clination to waste. 



145 CURRENT LITERATURE 

The final resultants in character are extremely manifold, because of 
the very complex relations of the anal erotic component^ among them- 
selves and in combination with other factors. From this complex arises 
some of the most valuable as well as some of the most unfavorable quali- 
ties. Among the first may be included strong individuality, decision, 
determination, love of order, talent for organization and efficiency, 
dependability, aesthetic refinement, and tenderness and tact in the affairs 
of the world. 

To the latter belong the inability to be happy, irritability and ill- 
temper, hypochondria, miserliness, narrowness of soul, limited intel- 
lectual vision and wearying spiritual obtuseness, love of domination and 
stubbornness — all traits which render life in society very bitter and 
difficult for their unhappy possessor. [C. Willard.] 

Reik, Th. Psychoanalytic Theory of the Affects. [Internat. 
Zeitschift. f. a. Psychoanalyse, Vol. iv, No. 3.] 

Observation of human behavior reveals two types, between v/hicn lie 
a whole series of transitional forms which at the same time separate and 
connect the extremes. In one group we find people who give free play 
to their emotions and in the other those who do not permit themselves 
affective outbreaks. In the first class the relaxation of the emotional 
psychic tension with the outbreak produces a feeling of relief and also 
a sense of inward strength, about the origin of which there cannot be 
the slightest doubt. It arises immediately from the consciousness of 
having preserved the ego from insult, and the root of this feeling is in 
the satisfaction of the primary narcissism in the unconscious. In illus- 
tration, the author gives a concrete example: A is insulted by B and 
gives vent to his anger in a manner unworthy of a civilized European 
gentleman — by boxing B's ears. The box on the ear is the obvious 
expression of the injured narcissism; the elevation of the egoistic feel- 
ing is the sign of the restoration of the narcissistic self-esteem. All 
the psychic adjustments to reality, all the renunciation of passion in the 
interest of culture, give way in a moment; the man becomes instantly 
a foolish, self-enamoured child — only playing the "grown-up." We 
are accustomed to regard the vita sexualis as a paradigm for all other 
affective experiences, and, therefore, without seeming to exaggerate it 
may be asserted that this outbreak of elementary affect with narcissistic 
satisfaction (in part accessible to consciousness) may be likened to the 
satisfaction which results from sexual congress. That fact that in some 
instances there is lowering of the egoistic feeling is no argument against 
this view, for this reaction only sets in later as result of reflection on 
the possible results of the outburst of passion, and is itself not without 
narcissistic value, for Freud has shown that the sense of guilt for an 
emotional outbreak is founded on a conviction of an ideal perfection of 
the ego, a narcissistic derivative. In this connection the author directs 



SYMBOLIC NEUROLOGY 147 

attention to the feeling of inferiority in neurotics, studied by Adler, stat- 
ing that the consciousness of inferiority really conceals a hypertrophy of 
narcissism — a fact which Adler failed to comprehend. If a simile be 
permissible, it may be said that the behavior of these neurotics is 
analogous to that of those rich persons who constantly bewail their 
poverty from fear that their wealth may become known. 

The author asserts that repression of affect also produces an eleva- 
tion of the unconscious narcissistic feeling. Following again the course 
of events in the concrete example: A is deeply insulted by B. His edu- 
cation as well as his psychic attitude prevent the direct satisfaction of 
his wishes for vengeance and the instantaneous payment of the injury 
by word or deed. The depression which is the immediate result of 
abstinence from motor satisfaction gives rise to a reactive strengthening 
of the narcissism and in such a situation a compromise is likely to take 
place. The censor guarding the threshold of consciousness permits the 
narcissism to reassert itself under a disguise, the verbal expression of 
which is " such a man could not insult me ! " The self-esteem is rees- 
tablished through the undervaluation of the opponent. The pleasure in 
immediate expression of affect after insult is of sadistic origin; that 
found in renunciation of expression is of maschochistic origin, though 
even in this latter case there is to a certain extent mobilization of sadis- 
tic tendencies. The desire to produce pain, repressed so far as the 
immediate opponent is concerned, may find expression in a violent pro- 
test against the entire cosmic order. The violent expression of the 
affect may be regarded as a belief in the " all-powerfulness of the deed ;" 
while those who permit themselves no emotional outbreak find satisfac- 
tion in belief in the " all-powerfulness of thought." In this substitution 
of thought for deed, phantasy magnifies the circumstances, giving them a 
more terrible, more complicated aspect, and the person who represses 
affect may come to wish to kill his opponent, even with horrible torture; 
he does not renounce vengeance, he merely postpones it. In the opinion 
of the author the connection of repression of affect or postponement of 
its satisfaction with the processes of sexual life is not as yet fully under- 
stood, but cases are by no means rare where a man who represses anger 
against his wife or sweetheart reacts later with ejaculation praecox or 
impotence. The mills of our emotions grind slowly but they grind 
exceeding sure. 

The role of shame and its connection with the reluctance to express 
strong emotion is most interesting. It seems as though the effusion of 
affect, the pouring forth of wrath bears some essential relation to normal 
ejaculation and the processes of excretion. The abstinence from effect 
may be analogous to the pathological, or, at least, abnormal processes in 
sexual life and excremental processes. 



Book Heviews 



Winkler, Cornells. Manuel de Neurologie, Anatomie du 
Systeme Nerveux. Deuxieme Partie. [De Erven F. Bohn, 
Harlem.] 

This is the seventh volume of Winkler's collected works and 
is new, constituting the second part of his anatomy of the 
nervous system which is incorporated in Vol. i of his Manual 
of Neurology. We have had occasion to speak of the first 
volrme of this Manual as the most comprehensive and thorough 
work on the anatomy of the nervous system of man as applied 
to practical neurological problems that we have. We have 
attempted to relate it to those classics such as Dejerine, von 
Monakow, Van Gehuchten, Cajal and Mingazzini and held it a 
peer if not a superior. 

The present volume finishes the discussion of the trigeminus 
which was begun in the first volume ; it also gives a complete 
resume of the eighth nerve which is most stimulating. 

The gasserian ganglion is here considered as an agglomera- 
tion of spinrl ganglia belonging to all of the spinal segments 
from CI to the most proximal of those which intervene for the 
innervation of the skin. In the first volume the full significance 
and importance of the trigeminus was not exhausted. Winkler 
has therefore devoted his first chapter in this volume to those 
problems relating to a study of these systems. The peripheral 
distribution follows the older accepted triple division from which 
the nerve has derived its name; the ophthalmic, the superior, and 
inferior maxillary. 

The ophthalmic branch is rich in autonomic and centrifugal 
secretory, vasomotor and pupillary fibers. Those least known 
are connected with lachrymal function. The glands receive 
stimuli not only by way of the lachrymal but also by way of the 
zygomatic through the ansa anastomotica. Their secretory path- 
way is sketched as follows: Through the glossopalatine they 
continue without interruption their preganglionic course by way 
of the major superficial petrosal in the sympathetic network, to 
arrive in the ciliary ganglion by the sympathetic roots of this 
ganglion. There they are interrupted as in an autonomic pre- 
vertebral ganglion and pass bv the long sensitive roots of this 
ganglion in the trunk of the V to reach the lachrymal gland. 
The ciliary ganglion is a prevertebral ganglion not only for the 
fibers of the lachrymal gland but also for the secretory fibers 
which remilate the internal liquids of the eye of the ciliary 
region. These very probably have their origin in the most 
proximal portions of the medulla. They accomplish their pre- 

148 



BOOK REVIEWS 149 

ganglionic course in the sympathetic plexuses of the carotids and 
cavernous sinus. They attain the ciliary ganglion by the sym- 
pathetic roots and after their interruption in the ganglion their 
postganglionic pathway corresponds to the short ciliary nerves, 
maybe also by the long roots of the long ciliary nerves. 

Notwithstanding the extreme complexities of the condensed, 
distorted and displaced metameres of the head region, Winkler 
gives us a singularly clear portrayal of one of the most difficult 
and important nerve regions of the body. The first hundred 
pages of the book are devoted to the trigeminus. 

The rest, 250 pages, takes up the eighth nerve. In the begin- 
ning of this chapter (VIII) on the system of the eighth nerve 
Winkler develops a slightly different concept of the anatomical 
situation. Whereas a tendency of late years has been to reason 
that the auditory and the vestibular apparatuses are two separ- 
ate and distinct nerve systems, Winkler holds that there is a 
much closer relationship between them than that which appears 
on the surface. Heretofore the sacculus, utriculus and semi- 
circular canals have constituted a static organ in which are 
originated the reflex activities necessary to the maintenance of 
our position in space, and the cochlea serves as an organ of hear- 
ing with no precise analogies to be found in lower animals. This 
general view Winkler maintains is a little too rigid and is only 
partially justified by the anatomical facts. 

The statocyst of lower animals, he shows, even in its simplest 
forms, performs more than one function. It gathers the local 
effects of exterior excitation, rhythmic or non-rhythmic; it regis- 
ters the movements of the surrounding liquid whether due to 
liquid or air shock, provided such stimuli determine a displace- 
ment of the body, and in its latest developed and most special- 
ized form, the organ is sensitive to other stimuli. Thus in 
Pterotrachea, a simple mollusc, the otoliths respond to air vibra- 
tions which have been transmitted to water. In a much simpler 
animal, Eucharis, Verworn has shown analogous mechanisms. 

In the mammalia there are to be distinguished at least four 
neuro-epithelial structures: [a] the striae nervosae in the semi- 
circular canals; [b] the maculae, or taches sensorielles of the 
utricle and saccule; [b] the cristae. or cretes sensorielles, of the 
ampoules; fd] organ of Corti, in the cochlea. The most recent 
of these is the organ of Corti, which reaches its complete develop- 
ment only in the mammalia. The cretes sensorielles of the 
ampoules are older ; the oldest of all the structures are those of 
the maculae. 

Winkler comoares the maculae to the primitive statocyst of 
invertebrates. These organs primarilv function for the main- 
tenance of general muscular tonus. They collaborate with the 
proprioceptive stimuli from the body. The function of the cretes 
sensorielles of the ampoules is of later evolution, and is more 
specialized. They have appeared for the registration of the 
movements of the head and for the head organs, chiefly the eye 



ISO BOOK REVIEWS 

movements. They remain in close liaison with the general tonus 
functions of the maculae. These regulatory functions are strictly 
condensations of geotropic reflex activities and are purely uncon- 
scious. Rhythmic activities have not yet taken on their social 
role. These are still to develop as various forms of more con- 
scious bodily displacement, marching, dancing, unison actions, 
etc., chiefly initiated through sound waves, and closely related 
with the development of laryngeal and buccal proprioceptive 
stimuli associated with the developing speech function. Thus 
the organ of Corti has come to be developed in response to a 
wider conscious acquisition of control of bodily movement, 
including tongue movements, i. e., speech, in its social orientation 
function. These reflexes for bodily orientation are no longer 
geotropic and entirely unconscious, they are taking on socio- 
tropic activities, partly conscious and in the highest cultural 
types becoming consciously socially valuable. The organ of 
Corti then is functioning in response to rhythmic or interrupted 
stimuli from the bodily organs and from the tongue through its 
symbol formations. How Winkler further develops his argu- 
ment must be left to the reader, who will be well repaid, we 
believe, to go carefully over the details [p. 127 et seq.]. 

Nowhere has the reviewer found so sound or penetrating a 
view of the development of the affective response to sound 
stimuli through muscular displacement and imitation. What the 
newer psycho-pathology is finding out with reference to uncon- 
scious social reactions to tone, to voice, etc., is well worked out 
by Winkler in his analysis of the unconscious reflex awakening 
of sonorous response to motor stimulus. Thus is laid down a 
true physiology of affective effector release from the sound — 
and vision — of muscular stimuli in the environment. We thus 
see how extremely valuable language has become as a type of 
release mechanism through gradual condensation of language 
symbols. Thereby the body and its organs are not required to 
go through severe and dangerous displacements if through lan- 
guage the necessary socially valuable protective reflex can be 
found. The reviewer has developed elsewhere a definite 
corollary of this in speaking of the affective discharge value of 
the symbol, particularly in its relation to a dynamic pathology 
in chronic disease of various types, and this complete analysis 
of the pathways through which and by means of which this is 
made possible is of much interest. The whole psychopathologi- 
cal argument relative to human response to emotional stimuli is 
brought nearer to structural facts in this masterly chapter on the 
eighth nerve. 

We would like to extend this review and take up a number 
of far-reaching suggestions developed by the author, but we can 
not. 

Here is a book to be read and digested. The Dutch school 
may be proud of its Dean, in that he has given a work of lasting 
benefit to his colleagues and to humanity. May he be spared 
many years to complete this ambitious task. Jelliffe. 






BOOK REVIEWS 151 

Bloomingdale Hospital. A Psychiatric Milestone. 1821-1921. 
[Privately Printed by the Society of the New York Hospital, 
1921.] 

This delightful memorial volume commemorates the 100th 
anniversary of the opening of Bloomingdale Hospital as a special 
department for the treatment of mental disorders in the New 
York Hospital. It gives a recital of the exercises held in June 
of 1921 as commemoration of this event. Dr. W. G. Russell, Super- 
intendent, tells us of the occasion and its mission. E. W. Shel- 
don, President of the New York Hospital, gives an Historical 
Review of the Institution, illustrated by old and new photo- 
graphs. Dr. Adolf Meyer writes on the Contributions of Psy- 
chiatry to the Understanding of Live Problems; Dr. L. F. 
Barker on The Importance of Psychiatry in General Medicine; 
Dr. Geo. D. Stewart presents the Greetings of the New York 
Academy of Medicine, Dr. R. G. Rowe, of London, speaks of the 
Biological Significance of Mental Illness, Dr. Pierre Janet, of 
Paris, writes on the Relation of the Neuroses to the Psychoses 
and Dr. W. G. Russell on the Medical Development of Bloom- 
ingdale Hospital. Various appendices and letters are added. 

The volume is an attractive one, giving concrete evidence of 
the advanced position taken by the Governors of Bloomingdale, 
and showing in a pleasing and practical manner what the present 
management is doing to further an advanced psychiatry, scien- 
tifically and humanely. 

Freud, S. Drei Abhandlungen zur Sexual theorie. Funfte 
unveranderte Auflage. [Franz Deuticke, Leipzig v. Wien, 
wks. 20.] 

These well known " three contributions," which have been 
translated in English, Russian and Hungarian, appear in a fifth 
unchanged edition. As in his introduction to the third edition, 
Freud specifically states that the present contribution is solely 
one which sets forth the possibilities of a psycho-analytic technic 
in throwing light upon the psycho-sexual development of human 
beings. That the objection of Pansexualism should be raised 
against the general principles, causes him some amusement at 
man's stupidity and encourages him. should he have ever claimed 
such a doctrine, to quote from masters of philosophy immemorial 
how important a part the god Eros of the Greeks has always 
played in human affairs. 

Bleuler, E. Lehrbuch per Psychiatrie, 3D Auflage. [Julius 
Springer, Berlin.] 

Two editions of Bleuler's Text-book of Psychiatry appeared 
during the period of the World War. The first in 1916, a 
second in 1918, and now a third, and we learn that an English 
translation is in progress. 

There are many reasons for the success of this book. In the 



152 BOOK REVIEWS 

first place it is a convenient size, approximately 500 large octavo 
pages, it is exceedingly well written, rnd above it it is written 
from a dynamic viewpoint. Descriptive psychiatry is not 
neglected, but Bleuler has avoided the manufacture of artificial 
monstrosities which, while excellent abstractions, have no real 
counterparts in nature. Furthermore, he has not lacked the 
courage to say how far present knowledge goes in its attempt 
to understand certain psychotic manifestations, preferring to 
state at times what we do not know rather than what we think 
we do. He has accented the value of psvchological concepts for 
the understanding of mental problems, maintaining, and we 
believe correctly, that a psychiatry without psychology is as 
futile as the omission of physiology in the understanding of 
internal medicine. In large part he has used psychological con- 
cepts which have been developed by him during the past 35 years. 
Bleuler has been one of the open-minded psychiaters who was 
able to affiliate much of the Freudian psychology into his own 
thinking — here are no simple Freudian repetitions, however, but 
a thorough reworking of many points of view in the light 
of his own experience. By reason of the compact setting neces- 
sary for a text-book his ideas of psychogenesis often suffer much 
abbreviation. They are always illuminating. 

So far as classification is concerned, Bleuler follows the gen- 
eral Kraepelian schedule. He does this since he believes it the 
most widely accepted and hence more readily followed, but also 
because the general fundamental ideas upon which Kraepelin has 
founded his system offer the best practical grounds for a classifi- 
cation. Certain points of variation he emphasizes in many of 
his chapters. 

While we would like to go into an extensive review of this 
interesting book, we must content ourselves with the general 
statement that we consider it the best single volume psychiatry 
with which we are acquainted. 

Pollak-Rudin, Robert. Grundlagen der experimentellen 
Magie: Magie als Naturwissenschaft. [Franz Deuticke, 
Leipzig and Wien. 

Two little pamphlets of telepathy and magic, etc., which get 
about as far as the general logical argument that because a pho- 
tographic plate must be developed in the dark, therefore the bag 
of tricks of the spiritualistic performer should not be questioned 
because they demand the dark. 

Semon, Richard. Bewusstseinvorgang und Gehirnprozess. 

[J. F. Bergmann, Wiesbaden.] 

Semon's biological work was of the highest order. As a 
pupil of Haeckel- he followed the naturalist's career according to 
the established customs of travel, collection, and study of his 
material. He accomplished much, and of this and other details 
of his rich life Otto Lubarsch gives an excellent resume in the 



BOOK REVIEWS 153 

forepart of this volume. The s?me well-known pathologist has 
edited this work posthumously. To the neuropsychiater 
Semon's works are valuable, since he tried to establish a work- 
ing concept of what is meant by phyletic memory as laid down 
in instincts, habits, patterns, modes, etc. From the first etchings 
on protoplasm by external stimuli, so ably sketched by Her- 
ing, what reactive capacities were left behind as " engrammes," 
as evidences of this writing into life, of experience. How were 
these built up by repetition of stimuli, and then how passed on in 
evolution. How discharged — ecphoriert — or thrown out as he 
expressed it. What, then, were the laws that not only governed 
the orderly collection of engrammes. but what were those laws 
that determined their discharge. The Mneme, or Memory, what 
was it as a complex synthesis of the engramm treasure? These 
and similar problems occupied the author for many years as he 
studied the fall of leaves in autumn, the budding of flowers in 
spring. What time stimuli, temperature stimuli, physical stim- 
uli, etc., etc., had become part of the habit working machine, 
be it the lilies of the field, or man. How is habit written into 
structure and finally as a last supreme synthesis of nature's laws, 
how are the phenomena of mental processes finally correllated 
and worked into nerve structure. 

Semon's Mneme. his Mnemische Empfindung and this final 
work contain an orderly presentation of the best series of 
thoughts along lines so constantly rising into the arena of the neuro- 
physchiater's observations as developing in social conduct:- — spinal 
pathway conduct — peripheral nerve conduct, etc., etc. We recom- 
mend it heartily. It may be noted in passing Semon was well ac- 
quainted with Samuel Butler's observations — a series of funda- 
mental biological ideas fortunr tely coming to their own concerning 
unconscious memory, etc. Jelliffe. 

Kretschmer, Ernst. Korperbau und Ciiarakter. [Julius 
Springer, Berlin, 56 mks.] 

The new constitution teachings are here made to contribute to 
the study of temperament. Red heads and fiery tempers are by- 
words of such liaisons, but the Tubingen Clinic is made to yield 
some interesting material. As here portrayed, Kretschmer 
determines three types of bodv structure which he names the 
Asthenic, the Athletic and the Pyknik types. Bauer has already 
outlined the more or less bovine nature of the asthenic type. 
These are long, thin, weak-muscled, soft-skinned people, with 
long noses, aesthetic profiles, pale and anemic, with thick curly 
hair and thin terminal hairiness, especially in their beards and 
moustaches. The athletic type needs no further characteriza- 
tion. It is well known. The pyknik habitus is bull-necked, big- 
chested, fat-bellied, with more graceful extremities — particu- 
larly definable in midde age. The head is large, round and deep, 
but not so high. 



154 BOOK REVIEWS 

These types, according to our author, have special predilec- 
tions for certain psychotic trends. The asthenic and athletic 
types run to schizophrenic dissociations — the pyknik types to 
cyclothymic trends. Further details of this generalization must 
be read in the original, which is filled with many suggestive 
analogies, out of which in time will emerge some relationships 
of interest if not of value. As the reviewer views himself in the 
glass he is convicted of the pyknik habitus. Lest his manic pro- 
clivities should betray themselves, he brings this review to a 
close with the reflection that it is an interesting, one-sided way 
of getting at things. The observations are worth checking up 
with other material. 

Erben, Siegmund. Diagnose der Simulation nervoser Symp- 
tome. Zweite Auflage. [Urban u. Schwarzenberg, Berlin- 
Wien.] 

We have called attention to the first edition of this valuable 
work. The second completely rewritten and enlarged edition 
is even more satisfactory, especially made so by the inclusion of 
the almost numberless opportunities of studying war situations, 
where simulation of all grades and varieties offered unparalleled 
facilities for observation, and differentiation of the material and 
judicial methods of handling the many situations developed. 

Fankhauser, E. Ueber Wesen und Bedeutung der Affek- 
tivitat. [Julius Springer, Berlin.] 

Vol. 19 of the Foerster-Wilmanns Monographs maintains the 
high grade of this most valuable series. Here the author pre- 
sents us with an extremely suggestive study in which he 
attempts an analysis of affectivity founded upon the reactions 
of the organism to light and to color. He, therefore, follows the 
general trend of recent workers who conceive of the activities of 
the human organism as a whole, in its response to physical and 
chemical environmental factors as playing upon the vegetative 
nervous system — including the endocrine organs. This analy- 
sis proceeds along the light and color r?nge. Psychical proc- 
esses are conceived of as physiological, with which no one will 
quarrel, and for him may be partly resolved into tropistic com- 
ponents, as Loeb and others have well shown, and as much recent 
American psychopathology concedes, notably Meyer, White, 
Kempf, Jelliffe and Timme, each in their minor-variant modes of 
approach. 

The chapter headings afford a slight insight into this stimu- 
lating research. They are: I. Affect Brain, Vegetative Ner- 
vous System and Internal Secretions; Chemical Foundations of 
Affective Processes their role in Manic-Depressive Psychoses 
and Paranoia. II. Parallelisms between Affect and Light and 
Color Stimuli. III. Conclusions on the Significance and Exten- 
sion of the Affectivity. IV. Affectivity and Association For- 
mation. V. Affectivity and the Psychoses. 



BOOK REVIEWS 155 

We cannot go further into the author's argument, which we 
consider a legitimate and fruitful hypothetical approach. By 
such methods we conceive it possible to understand the nature 
of human behavior more fully and welcome this effort with 
hearty approval. 

Schmidt, Albert K. E. Die paroxysm ale Lahmung. [Julius 
Springer, Berlin.] 

Periodic paralysis, familial or sporadic, is a rare syndrome, 
especially as manifested in its graver forms. In minor grades it 
is probably not as infrequent as has been supposed since West- 
phal and Oppenheim first gave it a fairly definite place in neu- 
rological nosology. 

The present small monograph of approximately sixty pages 
— vol. 18 of the Foerster-Willmans Monographs — presents an 
excellent review of the disorder which by reason of its thorough- 
ness, orderly, and logical arrangements will be welcomed by 
all neurologists. The excellent work by American neurologists, 
Burr, Taylor, Mitchell, Putnam and others, is given due credit 
and attention, as well as the work of others. This is attested by 
the excellent bibliography of 64 studies on the subject. 

The author deals with the initial stages, the well-developed 
attack, the recovery, complications, and interval periods. He 
discusses the hereditary features as essential, 81% of the cases 
showing marked familial traits, and in the pathogenesis accent 
seems to fall upon muscle ischaemia, through disturbance of the 
vegetative nerve control of the vascular supply of the affected 
muscles. The causes of the vascular constriction are not pur- 
sued further than the formulation of a specific disposition of 
these vegetative control mechanisms, in which suprarenal func- 
tioning seems to be involved. This is run as far back as being 
related to an interrelation between gastrointestinal function and 
sympathicotonia releasing increased adrenal material. 

Emotional factors, as related to adrenal functioning, are strangely 
neglected — otherwise the analysis of the syndrome is very pains- 
taking and illuminating. Jelliffe. 

Entres, Josef Lothar. Studien ueber Vererbung und Entste- 
hung geistiger Erkrankungen. Herausgegeben von Ern- 
est Rudin. Munchen III. Zur Klinik und Vererbung der 
Huntingtonische Chorea. [Julius Springer, Berlin, Mk. 88.] 
Vol. 27 of the Foerster-Wilmanns Monograph Series contains 
another detailed research study from the hereditary section of 
the Kraepelin Research Institute. This deals with a problem 
which has received special attention from American students, 
Huntington's Chorea. 

Entres does not get as far with the problem, it seems to the 
reviewer, as our American investigators have done. In fact, 
the Davenport and Muncie Studies, which grew out of Jelliffe's 
original material, are not mentioned. This is to be regretted. 



I5& BOOK REVIEWS 

Rudin himself has acknowledged this — since these most detailed 
analyses seemed to show the presence of a complex hereditary 
combination which, falling together, produce the disorder in 
Mendalian dominant fashion. Notwithstanding this lack, and 
also the overlooking of Roussy and Lhermitte's careful patho- 
logic analysis, the monograph is well worth while and deserves 
widespread reading. 

Froschels, Em.il. Kindersprache und Aphasie. [S. Karger, 
Berlin.] 

Here we have an entirely new tvpe of study of the aphasia 
problem. This is a series of formulations on the aphasia prob- 
lem from the standpoint of the development of speech in children 
and of their anomalies. In many relationships it may be studied 
with Pick's excellent monograph. As we purpose to present 
the entire aphasia problem in its more recent setting in the 
Journal, we shall not go further than say tha-t Froschel's most 
excellent monograph cannot be neglected by neuropsychiaters. 

Vorkastner, W. Epilepsie und Dementia Praecox. [S. Kar- 
ger, Berlin.] 

Convulsive seizures, epileptiform in character, have been 
described as an essential part of the dementia praecox picture for 
many years. Kahlbaum, in his Catatonia describes them. A 
small number of monographs have been written upon them — 
this one of the author's, the latest. In 162 pages he discusses 
this relationship, which, while it happens he does not consider 
essential, and furthermore he describes the combination of eoi- 
lepsy and dementia praecox. It is an interesting and valuable 
small volume. 

Potzl, Otto. Zur Klinik und Anatomie der reinen Worttaub- 

heit. [S. Karger, Berlin.] 

Potzl here discusses the relations between pure word deafness, 
conduction aphasia and tone deafness in a small but very well writ- 
ten monograph of some 80 pages. It makes up vol. 7 of Bonhoeffers 
series of Abhandlungen. 

Pure word deafness, subcortical sensory aphasia of Wernicke, 
or perception word deafness of Henschen, is a comparatively rare 
happening and Potzl's new case with anatomical findings pushes for- 
ward our understanding of this little observed aphasie syndrome. 
His patient showed a softening in the right T, of considerable ex- 
tent, occupying the middle and posterior thirds of this convolution ; 
also a second softening of the same side at the juxtaposition of 
the parietal and occipital lobes; on the left side there was a very 
small softening in the T, symmetrical with that of the right side. 
Further details must be consulted in the original. Potzl comments 
on Liepmann's pronouncement against a psychological appraisal of 
aphasia. He holds that whereas this may be true for so-called 



BOOK REVIEWS 157 

conscious psychology, the concepts of the newer psychology of Freud, 
make it possible to gain a deeper insight into the functions of speech 
and his conceptions with those of Semon, as particularly may be 
seen in V. Monakow's recent biological discussions, will be of much 
value in grasping the aphasia problem. 

Schrceder, P. Die Spielbreite der Symptome beim manischi- 

DEPRESSIVE IRRESEIN UND BEI DEN DEGENERATIONS PSYCHOSEN. 

[S. Karger.] 

In an excellent and clear manner Schroeder in 60 pages, attempts 
to show the present day criteria in clinical psychiatry by which the 
manic depressive group mry be marked off from the degeneration 
psychoses. That both formulations are far from being very definite, 
he admits, but notwithstanding this, he has given an excellent small 
monograph. 

Schmidt. Wilhelm. Forensch - Psychiatrische Erfaiirungen 
im Kriege. [S. Karger, Berlin.] 

The author is Privat Dozent in the Neuropsychiatry Clinic in 
Gottingen and served throughout the war. The present work is 
founded upon the study of 107 cases which came to observation at 
the Freiburg clinic from Jan., 1915, to the middle of 1917. 

Full case histories are given of a vast variety of psychiatric 
cases — Deser'ers, quarrelsome soldiers, alcoholic soldiers, various 
psychopaths, hoboes, prthological liars, careless and unstable sol- 
diers, Hysterias, Epilepsies with and without fugues, neurasthenics, 
defectives, schizophrenic and manic-depressives — these are all well 
described from the Hoche, Kraepelian and conservative school 
standpoints. This is about as fr r as war times permit. Deep psycho- 
logical studies in wartime are useless so far as practical issues are 
concerned. Even that such a view point obtains in the psychiatric 
world is passed up. 

Dol.ineer, A. Reitraege zur Aetiologie und Klinik der 

SCHWEREN FORMEN ANGEBORENER UND FRUH ERWORBENER 

Schwachsinnszustande. [Julius Springer, Berlin.] 
The feeble-minded — these we always have with us. Also a ple- 
thora of books about them. In order to justify a new one, the 
author maintains he has not mrde a recompilation of old opinions, 
but has introduced new principles of study which he endeavors to 
show are of practical importance in a realignment of old principles. 
The most significant features of this practical scheme are found 
in his third chapter, where the individual types are considered. 
Here the author outlines: I. Those due to intra uterine developmen- 
tal defects. II. Infectious, toxic, thrombotic or sclerotic processes 
affecting the brain and, III. Traumatic injuries of the brain, prena- 
tal, at the normal end of parturition rnd in the early days of the new 
born. 



158 BOOK REVIEWS 

We find much to commend in the author's very systematic pre- 
sentation of the gross injuries which bring about severe forms of 
feeble-mindedness. 

Hoffmann, Hermann. Studien ueber Vererbung und Entste- 

HUNG GEISTIGER STORUNGEN. HeRAUSGEGEBEN VON ERNEST 

Rudin. Munchen II. Die Nachkommenschaft bei Endo- 
gener Fsychosen. [Julius Springer, Berlin. Mks. 136.] 
The new Forschnngs Institut of Mental Diseases in Munich, 
under Kraepelin's stimulus, has developed a number of research 
scholars. Of these Rudin stands as conspicuous as a speck lly quali- 
fied worker in problems of heredity, as did the late lamented Nissl 
and Brodmann in their respective spheres. This study constitutes a 
second contribution from the hereditary section of the Foschungs In- 
stitute, under Rrdin's leadership — the author being an assistant in 
the Tubingen Clinic, who, as other assistants in the German psychia- 
tric clinics can spend part of a year or more on research problems at 
the Institute, a scheme of cooperation that might be followed more 
widely in our organized state services here. 

In Riidin's first contribution the ascend? nts in dementia praecox 
cases were studied. This monographic presentation of this research 
has already been reviewed in these columns. Hoffmann has de- 
voted this monograph, 235 pages (No. 26 of the Foerster-Will- 
mans Series), to a study of the descendents in the Dementia Prae- 
cox. Manic Depressive, and Epilepsy material of the Institut. He 
believes that distinct differences may be found in the descendant 
material in dementia praecox and manic depressive groups. Just 
what these are cannot be summarized here. They lead to too de- 
tailed a consideration for a review, but we consider that those inter- 
ested in psychiatric problems will be amply repaid by a study of this 
extremely valuable and careful piece of research work. 

Rixen, Peter. Die gemeingefahrlichen Geisteskranken im 
Strafrecht, im Strafvollzuge und in der Irrenplege. 
[Julius Springer, Berlin. Mrk. 48.] 

Medico-legal students will greatly enjoy this volume, although 
it deals with the procedures of zn entirely different nature from those 
that are prevalent in Anglo-Saxon jurisprudence. This juris- 
prudence, so far as the psychotic individual is concerned is most 
medieval and backward, but here and there as in Boston, under 
Herly's influence, and in Chicago, as guided by Adler and in other 
courts, a much more humane and progressive type of jurisprudence 
is making itself felt. 

Dana, Charles L. Text Book of Nervous Diseases. [Ninth 
Edition. William Wood and Company. New York.] 
The reviewer approaches a ninth edition with mingled feelings of 
admiration and proliferous discontent. Admiration that the back- 
ground of authority should have been so compelling as to have per- 



BOOK REVIEWS 159 

mitted — yea, encouraged — so many re-editions of an author's 
opinions. Discontent that this most excellent manual should not 
have been more consistently pruned and developed along the lines of 
more recent findings and hard won newer viewpoints. 

Even the most presumptuous of reviewers should admit that 
among American neurologists Dana has made most valiant efforts 
to keep in touch with the advance of neurological science. He un- 
doubtededly, in his general attitude, has shown — even though with 
certain reluctances — the wish to keep up with the march of prog- 
ress, and even if wonderingly inadequate at times, has sacrificed old 
and cherished beliefs for the inexorable logic of neurological 
evolution. 

Not that a text-book is by any means an adequate vehicle for the 
presentation of such gradual variations. It rarely is, and under the 
usual American book-printing limitations, m author is too infre- 
quently admitted the free hand he often might wish, to make radical 
rearrangements of his subject matter. But when with an accredited 
prestige of nearly thirty years behind it, even such limitations should 
be ruthlessly overcome. 

In general the work remains much the same as the last edition. 
Some newer material brought by the war's lessons has been incorpo- 
rated. This has been too slight, we feel. A new chapter on Dynamic 
Psychology hrs been added. Here Dana is more sympathetic to re- 
cent psychoanalytic work than in his previous edition. Psychoanaly- 
sis is even recommended, very sparingly, it is true. Psychogenic 
factors and their symbolic camouflages are freely recognized much to 
the value of the work and as evidence of the author's still plastic 
grasp upon the ever widening horizons of medical thought. 

In his preface the author would defend himself against being ac- 
cused of nonprogressive trends, holding that the many of the newer 
acquisitions are as yet too illy organized to present to students of 
neurology. We feel that the students are being somewhat mis- 
judged. A text-book can never present a solid phalanx of truth. It 
is only a fragmentary gesture after all, and ?s such should perhaps 
contain for the student not dogmatic categorical "estrblished prog- 
ress " only — but the many points of stimulus for further research 
that lie all along the pathway — still so woefully unillumined — as 
well. Concerning this, debatable questions arise, bit at least a 
student is entitled to know some of the things as yet unknown, in- 
stead of what too often is presented — a solid block of things which 
being established already have been left behind in the march of 
progress. In this stimulating quality we find the book lacking. It 
is something the student can grind on and learn by heart for exam- 
ination purposes. If this is the object of a text-book, well and good. 
It is an excellent one, even if the examiners are the sick patients 
needing relief, — but as a work that would lerd the student to look 
up the problems to further research upon every question raised, here 
we think it lacking. If the beginning and end of all wisdom is here 
contained, so be it, but if not wherein does the author suggest to the 
student where he can find further information? If, for example. 



160 BOOK REVIEWS 

he is not entirely content with being told that in pan; lysis agitans 
there are changes in the anterior horn cells, which of course is only 
a partial truth, or that the rubro-pallidal system is involved — how 
can he get more information on the subject? Certainly not here. 
Dana speaks too much of diseases as entities. Epilepsy is a 
" disease ;" paralysis agitans is a " disease." We hold that the day 
has gone by for this type of concept. Even the medical student 
talks of different types of pneumonic infltration is due to differing 
causes and hence to be handled differently. Certainly a postence- 
phalitic paralysis agitans is a different type of affoir from the usual 
chronic Parkinsonian syndromy. The only common points are topo- 
graphical. Similar structures are hit by different agents. These 
kinds of problems rre all ruled out by a rigid doctrinal attitude, 
which no doubt is conceived of a being " good for the student." The 
reviewer differs radically from the author on this point, and finds 
the too rigid formalism of direct positive statements about this and 
that, not only misleading, but even often untrue. Such kind of 
teaching, if pushed too far, leads to the manufacture of parrots and 
not to real investigators. American medical students suffer too 
much from this type of teaching, an issue which is not the special 
attitude of the reviewer but a universally recognized defect in edu- 
cational methods throughout, and one which the author himself de- 
plores. 

Muller, L. R. Das vegetative Nervensystem. [Julius Springer, 

Berlin.] 

A monographic treatise on the vegetative or visceral nervous sys- 
tem has long been a desideratum. Higier's excellent short work has 
heretofore occupied the field. Muller, with Dahl, Glaser, Greving, 
Renner and Zierling,has written an anatcmy, physiology and psychol- 
ogy of the vegetative nervous system in 229 pages with t68 illustra- 
tions. It is by far the best available anatomy on the subject — a less 
satisfactory physiology and a disappoin'ing psychology. 

He has intentionally delryed attempting a pathology of the vege- 
tative nervous system, notwithstanding its major importance, since 
he holds the material has not yet been sufficiently worked over to jus- 
tify such a volume. 

In a sense the work must be called a general orientation in the 
field. The difficulties rre great, since the vegetative nervous system 
is phyletically so old and so overladen with the myelinated somatic 
sensori-motor system, but neurological science is slowly having 
offered to it data upon which a real dynamic physiology and pathol- 
ogy can be reared. We welcome this more than valuable contri- 
bution to that end and hooe the day will soon arrive when Muller 
will give us a more functional view of this whole field. No one is 
more competent to do it and as soon rs all of the war vivisections 
have been completely collected and anrlyzed. marked progress is to 
be expected. Spiegel's excellent and recent Referat is an indication 
of the richness of this material which we hooe soon to see codified* 
and systematized for practical neuropsychiatric work. 



VOL. 55. MARCH, 1922. No. 3- 

The Journal 

OF 

Nervous and Mental Disease 

An American Journal of Neurology and Psychiatry, Founded in 1874 



\U 



Original Articles 



CLINICO-PATHOLOGIC NOTES ON SOLITARY 
TUBERCLE OF THE SPINAL CORD* 

By William Thalhimer, M.D. 

COLUMBIA HOSPITAL, MILWAUKEE, WIS. 
AND 

George B. Hassin, M.D. 

ASSOCIATE PROFESSOR OF NEUROLOGY, UNIVERSITY OF ILLINOIS COLLEGE OF MEDI- 
CINE; HISTOLOGIST TO THE ILLINOIS STATE PSYCHOPATHIC INSTITUTE; AT- 
TENDING NEUROLOGIST. COOK COUNTY HOSPITAL, CHICAGO, ILLINOIS 

It is generally admitted that so-called solitary tubercles of the 
brain or spinal cord are usually, if not always, associated with a tu- 
berculous meningitis. On the other hand, it has been noted that a 
tuberculous meningitis, as a rule, spares the substance of the brain 
or spinal cord, 1 which, if involved, become so, as generally believed, 
either through the direct spreading of the morbid condition from the 
diseased meninges to the adjacent parenchyma or through the si- 
multaneous involvement of the latter by the tuberculous process. 

This question of mutual relationship between tuberculosis of the 
parenchyma and that of the meninges is of great interest, for it has 
some bearing on the important problem of the mode of spread of an 
infection from the spinal cord to the meninges and vice versa. Soli- 

* From the pathology laboratories of Illinois State Psychopathic Insti- 
tute and Cook County Hospital, Chicago, Illinois, and laboratories of Co- 
lumbia Hospital, Milwaukee. 

1 See for instance Sittig. O., Ueber einen eigenartigen Destruktions- 
prozess der Hirnrinde bei einem Falle von Hirntuberkel, Zeit. f. d. ges. 
Neurol, u. Psych., XXXIII, 1916, p. 301. 

[161] 



162 W. THALHIMER AND G. B. HAS SIN 

tary tubercles of the spinal cord as well as of the brain are espe- 
cially suitable for such studies since they represent circumscribed, 
well defined formations, divided from the pia-arachnoid membranes 
by more or less preserved tissues. They represent, as it were, iso- 
lated foreign bodies against which the nervous system reacts in va- 
rious ways and of which it tries to rid itself. On the other hand, 
such tuberculous formations are by no means a very common occur- 
rence and are therefore also of sufficient clinical interest. Of the 
three cases that formed the basis for the present pathologic study 
one was a case of a tubercle of the optic thalamus, one of the spinal 
cord reported by Bassoe (i) and the third was also a case of solitary 
tubercle of the cord that came under the observation of one of us 
(Thalhimer) and will be recorded in full, together with a brief re- 
port at the end of this contribution of similar cases gathered from 
the literature. The case of the optic thalamus tubercle could not 
be studied in detail as only fragments of this tumor were available, 
the brain having been destroyed soon after the autopsy made six 
years ago. 

Report of Case and Discussion of the Clinical Features of 
Solitary Tubercle of the Cord (Doctor Thalhimer) 

Patient S. V., 28 years old, admitted 2/6/20 to Columbia Hos- 
pital, Milwaukee, complaining of backache and stiff back. 

Family History: Unimportant; no history of tuberculosis. 

Past History: Unimportant. 

Present History: For about a year before admission back- 
ache and stiff" back had prevented the patient from bending his back 
as he had formerly done. 

Physical examination : No abnormality found ; all reflexes nor- 
mal. Examination of chest revealed few rales at right apex, no signs 
of consolidation. Temperature occasionally rose to 101° F. 

X ray examination: Showed marked evidence of beginning os- 
teophytes at practically all of the corners of the lumbar vertebrae. 
Transverse processes of the fifth lumbar vertebra are large and 
shadows overlap the ileum. The condition was considered one of 
osteo-arthritis of the spine and a plaster jacket was applied before 
patient left the hospital. 

5/13/20: Readmitted to the hospital. The condition has gradu- 
ally grown worse, there being more pain and more limitation of 
motion of spine. Plaster cast reapplied. 

10/12/20: Patient again returned to the hospital, with the origi- 
nal symptoms increased and with a new group of symptoms ; loss of 



SOLITARY TUBERCLE OF THE SPINAL CORD 163 

power in both legs with spasticity ; numbness of both legs ; urinary 
difficulty and constipation. When he left the last time he had prac- 
tically only backache. He left hospital in a body cast which was 
applied for about three and one half months. When removed, the 
pain in lower part of spine had disappeared, but instead there was 
a pain in upper part of spine between the shoulder blades, the lower 
part of spine being immobile. Pain in spine is intermittent, some 
times sharp, sometimes dull. Patient frequently awakes with a 
feeling that someone has hit him on the back ; a sort of stinging sen- 
sation. About three weeks ago he felt extreme weakness in both 
legs and went to bed. Since then, he has lost entire use of both legs. 
At frequent short intervals either leg goes into a spastic condition 
lasting for just a moment. Patient has no pain in legs, only feeling 
of numbness. Ever since he left the hospital previously he has had 
a gradually increasing constipation. He has had no bowel move- 
ments at all lately without use of cathartics. Patient states that 
there is a sense of numbness in the rectum, and bowels. Patient has 
had no involuntaries but for the last three weeks he cannot tell 
whether he has urinated or not. He is able to control the passage 
of urine but does not know wheh the flow starts or ceases. 

Physical examination: While lying quietly in bed has a clonic 
spasm of either leg every few moments. 

Head: Scalp: Eyes: Negative. 

Lungs: There are a few scattered, fine, sub-crepitant rales near 
hilus of left lung. There is no bronchial breathing. No percussion 
dulless. 

Heart: Negative. 

Abdomen: On right side of abdomen there is impaired sensation 
to pain and touch, below seventh rib, and this extends down to toes, 
with anesthesia just below the right costal margin. On left side 
there is a band of hyperesthesia at the level of the umbilicus. There 
is slightly impaired sensation to touch and pain on left side of ab- 
domen and down left extremity. Posteriorly the areas of impaired 
sensations correspond roughly to the anterior findings. The same 
holds true of legs. The spine is negative to palpation. 

Reflexes 10/23/20 Right Left 

Knee jerks -f- (- +++ 

Babinski -f-f +++ 

Ankle clonus -j-+ 4— r— r- 

Oppenheim -\- -f- 

Chaddock -f- -j- 

Gordon O -f- 

Cremasferic O O 

Abdominal O -+■ 



164 W. THALHIMER AND G. B. HASS1N 

X ray examination: Osteophytes of the entire lumbar and 
eleventh and twelfth dorsal vertebrae. 

10/15/20: Patinet was unable to void urine and from this time 
on had to be catheterized. 

Lumbar puncture: Only about 3 cc. of bright yellow, clear fluid 
could be obtained. Six cells per c. mm. — all small mononuclears. 

Wasscrmann (spinal fluid) : Negative. 

Blood Wassermann: Negative. 

The diagnosis arrived at was that there was a pressure lesion of 
the spinal cord at about the fifth-sixth dorsal vertebrae. Because 
of the osteoarthritic condition of the spine it was thought that pos- 
sibly in some very peculiar way, which however could not be demon- 
strated with the X ray, some ossifying process was causing this pres- 
sure. The diagnosis of spinal cord tumor was, of course, seriously 
considered, but this diagnosis was put in a secondary position because 
of the long history of the ossifying spondylitis. 

10/26/20: Laminectomy by Doctors Gaenslen and Le Cron: ex- 
posure of the cord at the level of the fourth, fifth and sixth dorsal 
vertebrae, no evidence of pressure. Pulsation normal. Dura opened 
and probe was passed upwards and downwards for a distance of at 
least three vertebrae in each direction without detecting any abnor- 
mality. The exposed cord was elevated laterally on each side and 
the spinal canal thoroughly explored; no abnormality was found. 
Wound was then closed. 

12/6/20: The paralysis and sensory disturbances continued to 
progress. 

Spinal puncture: As previously only 3-4 cc. of bright yel- 
low, clear, spinal fluid could be obtained. This fluid soon clotted in 
the tube (typical Froin syndrome). A pressure on the jugular 
.veins at the root of the neck normally causes an increased flow of 
spinal fluid (as demonstrated by Ayer) but caused no further flow 
of spinal fluid in this case. There was a 5 mm. ring of albumin ; 
globulin positive, and with Fehling's solution, instead of reduction, 
. a violet biuret reaction was obtained. 

The diagnosis was now inevitable that there must be a spinal cord 
tumor above the level where the cord was previously exposed. 

2/4/21: Second operation by Doctors Gaenslen and Le Cron: 
The spinal cord beneath the first, second, third and fourth dorsal 
vertebrae was exposed. Through the dura a palpating finger dis- 
closed a hard mass, feeling like a bony prominence from the anterior 
wall of the spinal canal, rather diffuse, the size of an almond, and at 



SOLITARY TUBERCLE OF THE SPINAL CORD 165 

the level of the second dorsal vertebra. The dura was then opened 
and an intramedullary tumor was visible as an ivory white mass 
alxnit .6x1 cm. in size extending slightly to the left of the median 
line and surrounded by a zone of dilated capillaries about 3 mm. 
wide. There was a very large, longitudinal vein in the pia, slightly 
to the right. The cord was incised longitudinally and a small portion 
of the tumor removed for examination. It was then found that the 
tumor began to separate from the structure of the cord, and with a 
small brain spatula the entire tumor was gradually enucleated. This 
left a marked defect in the cord, only about one-third of the original 
cord structure being left on the extreme right side of the defect. 
The incision was closed in the usual manner. 

Specimen removed at operation — description gross: Specimen 
consists of a cylindrical piece of tissue 2 cm. long by 1.1 cm. in di- 
ameter. The surface is rough, as though it had been dissected out 
and the ends more or less flattened, but slightly rounded at the edge. 
It is very firm, about the consistency of a uterine fibroid. The sur- 
face is cream colored and the cut surface, from section which had 
already been made in the longitudinal direction of the cylinder, is 
creamy yellow in color. The tissue is fairly homogeneous, the cut 
surface being smooth and glistening and slightly translucent. On 
further sectioning there is found in the center portion an irregularly 
rounded area about 7 mm. in diameter, which is slightly more yel- 
lowish than elsewhere and slightly opaque, giving the appearance of 
an early stage of degeneration. 

2/17/21 : There was no improvement in the patient's condition, 
since the operation, he gradually lost ground, became more and more 
emaciated and ceased to breathe on this day. 

Autopsy: Anatomical Diagnosis: Solitary tubercle (removed at 
operation) of spinal cord, osteoarthritis of spine 2 and bilateral, ili- 
opsoas, tuberculous abscess. Scars (tuberculous) at the apices of 
both lungs. 

Body of an extremely emaciated young man. There are large 
bed sores present over both hips and buttocks. From the upper 
dorsal region of the back there is a scar from an old healed surgical 
incision in about the midline, about 15 cm. in length, extending 
from about the seventh or eighth dorsal vertebrae to the fourth. 
Above this scar there is a more recent, healed surgical incision ex- 

2 This was probably tuberculous in origin, because the bilateral iliopsoas 
abscesses were tuberculous. No tuberculous focus, however, was found in 
the vertebrae, and the productive osteoarthritis of the spine (as shown by 
the x ray) is not commonly found in Potts' disease. 



166 W. THALHIMER AND G. B. HASSIX 

tending upwards from the older scar to the region of about the first 
dorsal vertebra. The tissues beneath the old scar are firm and well 
healed. Beneath the new scar the tissues are infiltrated with a thick, 
purulent exudate as far as the dura of the cord. The laminae be- 
neath both of these scars are absent but beneath the older scar there 
has been considerable bone regeneration immediately next to the dura. 
The dura was exposed from the region of the seventh cervical verte- 
bra to the eighth dorsal. The dura is found intact and two suture 
lines identified because of the black silk sutures. Each of these are 
about 8 cm. in length and separated from one another by about 3 cm. 
The segment of the cord thus exposed was removed with the dura 
intact. The dura was then opened on the dorsal side, and beneath 
partial defect in the cord. The upper and lower ends of this defect 
are rounded and reddened (the defect is not quite so large as it was 
at the time of operation). There are no gross indications of menin- 
gitis. The bodies of the vertebrae beneath the segment of the cord re- 
moved were opened (from the rear) with a chisel and no definite 
pathological condition found. The bodies of the vertebrae were ex- 
posed from the front by removing all of the thoracic and abdominal 
viscera. Alongside the vertebral column, extending from the level of 
the tenth dorsal vertebra downward, including the sacrum, and situ- 
ated beneath the iliopsoas muscle and in the retroperitoneal space on 
each side of the spine is a rounded bulging mass. When incised 
throughout its length this is found to consist of a diffuse, thick, 
purulent and caseous material. There is a slight amount of new bone 
present on many of the vertebrae at the margin of the intervertebral 
disks extending outwards for about one-half cm. No areas of bone 
destruction could be found on inspection. The anterior portions of 
the bodies of the vertebrae were then removed with a chisel, from the 
fourth lumbar to the second dorsal. No marked change was found 
in their structure, but the tenth and eleventh dorsal were somewhat 
pale in color and appeared somewhat denser than the cancellous 
bone in the other vertebrae. 

Thoracic and abdominal viscera: The apex of the right lung was 
densely adherent to the pleura and showed beneath the pleura a firm, 
scar like area which on incision was found to contain calcium. This 
area is 1 x 2 cm. The left apex was also adherent and shows a 
■smaller scar and smaller area of calcium. 

The tracheobronchial lymph nodes are somewhat larger than nor- 
mal but otherwise appear normal. The remainder of the viscera 
appeared normal. 



SOLITARY TUBERCLE OF THE SPIRAL CORD 167 

Microscopical: Cancellous bone from the body of one of the 
tenth dorsal vertebrae — three sections, including a portion of the in- 
tervertebral cartilaginous disk : The bone structure is normal, 
the bone marrow throught practically all three sections shows no fat, 
but is made up of hemopoietic marrow. Near the edge of one 
section is a small area of coagulation necrosis, which may be casea- 
tion. 

Iliopsoas Fascia: Shows many typical tubercles, with giant cells 
and caseous material. 

Discussion 

The case (S. V.) reported here showed several clinical features, 
which, together with some data from the literature, are worthy of a 
brief discussion. 

The spinal cord symptoms and signs were those of tumor of the 
spinal cord. Had not an osteoarthritis of the spine preexisted, 
which suggested the possibility of pressure On the cord from this 
process, the preoperative diagnosis should have been " tumor of the 
spinal cord." Therefore, solitary tubercle of the cord must be con- 
sidered in all cases with symptoms of primary tumor of the cord. 

A complete Froin's syndrome was present in the spinal fluid, i.e., 
clear, yellow fluid which clotted spontaneously. This is considered 
by some observers, in the absence of history of trauma, to be pa- 
thognomonic of a spinal cord tumor. Ayer (7) gives a broader sig- 
nificance to this phenomenon, and believes it to indicate spinal cord 
compression. 

There was evidence to show that the spinal cord was not only 
compressed, but the spinal carial was completely blocked at the level 
of the tubercle. This was demonstrated by a procedure devised by 
Ayer. He has demonstrated in animals that with a needle in the 
cisterna magna and one in the spinal canal, pressure on the jugular 
veins at the root of the neck causes both the intracranial and intra- 
spinal pressure to increase with a jump. When the spinal canal is 
blocked, the pressure increases above the level of compression, but 
not below it. Ayer (7) has therefore suggested that this phenome- 
non may be used in demonstrating a block in the spinal canal by 
simply noting, with the aid of a lumbar puncture performed below 
the spinal cord lesion, whether pressure on the jugular veins in- 
creases the intraspinal pressure or not. In cases with the spinal 
canal patent, the intraspinal pressure always becomes increased. 
We have confirmed this finding of Ayer in a large number of lum- 
bar punctures. Pressure over the jugulars has always caused the 



168 W. THALHIMER AND G. B. HASSIN 

spinal fluid to run from the needle a great deal more rapidly. Some- 
times it has even spurted out, whereas, before application of the jug- 
ular pressure, and after it, the fluid came out slowly, drop by drop. 

Repeated lumbar punctures in the case reported yielded only 
from one to four cubic centimeters of fluid and pressure on the 
jugulars caused no further flow. We, therefore, felt certain that 
whatever the nature of the lesion it had caused a complete block ol 
the spinal canal. 

This conclusion calls attention to an observation made at the 
first operation. A probe was passed between the dura and cord be- 
yond the region where the tubercle was found at the second opera- 
tion. Nevertheless, in spite of the functional block in the spinal 
canal, the probe met no obstruction. Also, it was impossible to de- 
tect the presence of the enlargement caused by the tubercle. The 
inability to detect a spinal cord tumor by this method is well recog- 
nized and is again verified in this case. The lesson to be learned is 
always to be sure in operating cases with cord level lesions to per- 
form the laminectomy high enough, and never to trust the evidence 
obtained by passing a probe in the spinal canal beyond the exposed 
area of cord. 

The question of operability of tubercles of the spinal canal and 
their removal suggests itself. The tubercle in this case was easily 
enucleated, as was also possible in two reported cases ; those of 
Veraguth and Brun, and of Elsberg. In the reported cases complete 
functional cures occurred. In our patient there was so much loss 
of spinal cord substance that there was no return of function, and 
the patient died from exhaustion and other causes secondary to his 
complete paraplegia. 

It is believed that when the tubercle is solitary and not multiple, 
and if there is not an extensive generalized tuberculosis, operative 
removal is indicated in spite of the localized tuberculous meningitis 
situated about the tubercle. There are several reasons for this 
opinion. The tubercle is usually easily enucleated. The meningeal 
tubercles are thought to be secondary to the solitary tubercle, and 
the removal of the primary focus would get rid of this feeding 
focus. There seems to be a tendency for the secondary meningitis 
to regression and healing after the solitary tubercle is removed as 
is demonstrated by the recovery of the successfully operated cases 
of Veraguth and Brun, and Elsberg. This tendency to spontaneous 
cure of the localized tuberculous meningitis after operative removal 
of the nearby solitary tubercle of the cord can be considered as 



SOLITARY TUBERCLE OF THE SPINAL CORD 169 

analogous to good results in tuberculous peritonitis after abdominal 
exploration. It is well recognized that many cases of tuberculous 
peritonitis regress and even go on to apparent cure after simple 
laparotomy. The belief is that by this procedure reactive phe- 
nomena are stimulated which enable the body to overcome the tuber- 
culous infection. It seems possible that the same process would oc- 
cur with a localized spinal tuberculous meningitis and therefore 
this meningitis need not be considered as a contraindication to opera- 
tion for removal of a solitary tubercle of the cord. 

Microscopical Examination of Tubercle Removed 

at Operation and Spinal Cord Removed at 

Autopsy (Doctor Hassin) 

This included the damaged portion of the spinal cord (contain- 
ing the cavity), the tubercle itself (removed during the operation 
and thus leaving the cavity), the areas above and below the cavity, 
the meninges (including the dura) and the spinal roots. The tu- 
bercle and its remnants around the cavity exhibited a great mass of 
distinct foci, or miliary tubercules, which stained poorly. The ma- 
jority were caseous, granular in appearance and without vessels, 
while some showed vessels with walls more or less thickened or 
were made up of concentric rings of connective tissue fibres. The 
latter frequently formed a distinct network whose meshes harbored 
ill defined cellular elements. Some resembled fibroblasts, but hema- 
togenous elements, such as lymphocytes, polyblasts, plasma cells or 
leucocytes could not be discerned. Other tubercles showed no 
caseation, no vessels, but merely fragments of connective tissue 
fibres without any traces of cellular elements (Fig. 1). The same 
figure shows a tubercle containing a blood vessel surrounded by a 
homogeneous area. Some tubercles exhibited blood vessels with a 
well preserved elastica which was often doubled, split or broken up, 
the endothelial cells markedly swollen and protruding into the lumen 
usually detached from the adjacent subendothelial layer, the empty 
space packed with various mononuclear elements. The adventitia of 
such vessels was always thickened, hyperplastic and packed with an 
enormous amount of broken up, disintegrated, ill defined cell ele- 
ments. 

There were again tubercles, granular, badly stainable, containing 
some giant cells and enveloped by a capsule of fibrus tissue. They 
either showed no vessels at all, or vessels with an occluded lumen, 
thrombosed or filled with a mass of detached endothelial cells. In 



170 



IV. THALHIMER AND G. B. HASSIN 



short, the miliary tubercles which made up the mass of the solitary 
tubercle were either fibrous formations or in a state of cheesy de- 
generation (cheesy tubercles). The latter represented regressive, 
broken up tubercles, the former a stage of healing. Quite often the 
miliary tubercles were divided from each other by a dense network 



Fig. i 




In the upper half of the photomicrograph two tubercles are distinctly seen. 
One — to the right, around a patent blood vessel containing some red cells — 
is in the process of formation, the one — to the left — is completely formed 
and partly broken up. Use hand lens. Alzheimer-Mann stain x 160. 



of connective tissue. The latter sometimes was of unusual thick- 
ness, hyaline in appearance, enclosing within its meshes various un- 
definable, mononuclear elements as well as masses of detritus. 
Marchi stained specimens revealed in such areas minute dust-like 
particles of fat as well as occasional fragments of broken up nerve 
fibres, freely and irregularly scattered. As a rule, however, the 



SOLITARY TUBERCLE OF THE SPINAL CORD 



171 



tubercles showed no traces of nerve tissue, glia cells or glia fibres, all 
these ectodermie elements having been replaced by connective tissue 
and masses of the cheesy islands — degenerated tubercles. 

The foregoing tubercle masses that made up the solitary tubercle 
had been surrounded by and divided from the adjacent pia by a nar- 
row zone rich in capillaries and small vessels which were intensely 

Fig. j 








'**'J 



r 




The lower half of the photomicrograph representing the spinal cord covered 
with tubercles is divided from the upper half — the infiltrated and thickened 
dura — by a split and infiltrated pia (p. p. p.) Bielschowsky stain x 60. 

hyperemic and sometimes infiltrated. This area also showed an 
abundance of blood pigment granules, glia nucli, scattered red cells, 
numerous rod cells (Stdbchctizcllen) and white blood cells with a 
light biscuit-shaped nucleus much resembling Maximow's polyblasts. 
In general, this zone, so called zone of hyperemic vessels (hyperemic 
zone), showed no definite structure, the hemosiderin and red cells 
having been evidently the result of the operation on the cord. 



172 IV. THALHIMER AXD G. B. HASSIX 

This hyperemic zone was closely followed by the spinal men- 
inges, pia arachnoid and dura, with which it was blended forming 
one mass (Fig. 2). In this, at first glance, it was rather difficult to 
discern the component structures. Only with special stains, such 
as Alzheimer-Mann, Jacoby-Mallory, van Gieson, was it possible, 
for instance, to single out the pia mater, to follow up the course or 
define the exact relationship of this membrane to the spinal cord. 
It appeared as a distinct strand of connective tissue, separated from 
the spinal cord, and not invaded or transgressed by the tuberculous 
masses (Fig. 2). This membrane was rather excessively vascular- 
ized and showed an abundance of reactive phenomena in the form 
of small scattered inflammatory foci. The blood vessels were not 
occluded, but were often infiltrated with plasma cells and lympho- 
cytes. The cellular infiltration was in some instances quite marked 
appearing as dense, poorly stained rings or muffs around smaller 
blood vessels and much resembling a caseous tubercle. 

The vascular infiltrative phenomena were associated with other 
reactive phenomena in the pia, principally in the form of abundant 
proliferation of fibroblasts, round or spindle-shaped cellular bodies 
containing large pale nuclei. Equally numerous were polyblasts, 
plasma cells, macrophages, gitter cells, and comparatively fewer, 
though quite numerous, polymorphonuclear cells and very scarce 
giant cells, — all these elements were mixed with a great number of 
newly formed pial capillaries especially at the level of the tubercle. 
The foregoing inflammatory phenomena were, however, also quite 
in evidence in the portions of the pia situated above and below the 
area occupied by the latter. 

The dura (Fig. 2) was even more densely infiltrated than the pia 
arachnoid with which it was blended, the subdural space being totally 
obliterated. The cellular infiltration involved all the layers of the 
dura as well as the so called dural interspaces which were densely 
packed with lymphocytes, plasma cells and fibroblasts, the last being 
of especially large size and densely surrunding the thickened ves- 
sels. The epidural layer was very rich in giant cells and in large 
plasma cells containing as many as six nuclei, while the connective 
tissue as well as the elastic fibres appeared quite normal. The 
dural changes were, like those in the pia, widespread, that is to say 
they were present at every level of the spinal cord, but were espe- 
cially marked around the tubercle. The same infiltrative and pro- 
ductive phenomena were present in the roots, especially the posterior 
ones, where, in addition, marked degenerative changes could be seen. 



SOLITARY TUBERCLE OF THE SPINAL CORD 173 

Thus, many fibres appeared degenerated or were totally lacking, 
while the endo-, peri- and epineurium were thickened and hyper- 
plastic. Such root changes were most marked in the region of the 
spinal cord harboring the tubercle but were more or less present in 
other areas at a distance from the latter. 

A few words might be said as to the condition of such other por- 
tions of the spinal cord. The lumbar or cervical regions, for in- 
stance, exhibited only signs of secondary degeneration, which in- 
volved both the gray and surrounding white substances, the marginal 
areas being comparatively but mildly affected. Stained with Marchi, 
the sections showed an enormous amount of black globules, while 
Alzheimer- Mann or Jacob-Mallory stains brought out the remark- 
able glia changes which are so typical for secondary nerve degenera- 
tion. Thus, the glia tissue almost entirely replaced the parenchyma 
— the gray as well as the white substance — showing either as large 
monster glia cells with abundant protoplasm containing an eccentric, 
chromatin rich nucleus and numerous ramifying processes, or they 
showed as myelophages, with abundant large vacuoles harboring 
remnants of myelin or as various form of gitter cells gathered 
around the smaller vessels and capillaries. In none of these areas 
were signs of tuberculous material or of inflammation present. 

General Summary and Discussion of Pathology of 
Tubercle of the Cord 

1. Transformation of a portion of the spinal cord into a mass of 
miliary tubercles, partly cheesy, partly fibrous. 

2. Typical secondary degeneration of the spinal cord above and 
below the tuberculous mass. 

3. Extensive lepto-, pachy- and peripachymeningitis with in- 
volvement of the spinal roots, especially marked at the level of the 
spinal cord harboring the tubercle. 

4. Total absence of the inflammatory phenomena of myelitis in 
the areas not affected by the tuberculous process. 

The outstanding feature was the loss of the usual array of ecto- 
dermic and mesodermic elements of the spinal cord and their re- 
placement by a mass of tubercles. As a matter of fact, only the 
mesodermic portion of the spinal cord, the blood vessels and the 
septal connective tissue, were in evidence, while the ectodermic ele- 
ments — the glia cells, glia fibres, ganglion cells and the majority of 
the nerve fibres — were entirely destroyed. The mesodermic ele- 
ments, in contrast, showed remarkable phenomena, especially in the 



174 W. THALHIMER AND G. B. HASSIN 

vessels. The latter surrounding the tubercles were often hyper- 
emia; other blood vessels within the tuberculous tissues possessed 
unusually thick walls and greatly narrowed lumen. In other ves- 
sels the walls were not only hyperplastic but also infiltrated, the 
lumen greatly narrowed by a proliferative endarteritis. Some ves- 
sels showed only a distinct, split, doubled or broken up elastica. 
Finally there were vessels with an entirely occluded lumen sur- 
rounded by a caseous granular mass much resembling a cheesy 
miliary tubercle. 

While such profound changes in the spinal cord tissues did not 
set up inflammatory phenomena in the adjacent parenchyma, they 
did so to a marked extent in the spinal meninges, the pathologic 
phenomena in the latter presenting a striking contrast with those 
in the spinal cord tubercle. It can be seen that the latter constitute 
a dying, regressive or degenerative tuberculous process, while the 
meninges represent the same process in a young stage in the form 
of an abundance of hematogenous and histogenetic elements (fibro- 
blasts). Both these groups of elements thus seem to be instrumental 
in the genesis of tuberculous lesions, ultimately leading to the for- 
mation of tubercles. 

The dissimilarity in structure of the tubercles in the meninges 
and spinal cord is due to the stage of formation as well as to the char- 
acter of the tissues harboring them. The importance of these two 
factors was brought out and conclusively proven by the experimental 
work of Fieandt (2) who was able to follow the genesis and grad- 
ual growth of a tubercle formation by numerous experiments on 
animals. The growth of the tubercle in meninges, in our case, 
showed principally as marked perivascular infiltration which was 
also in evidence in the miliary tubercles of the spinal cord. In the 
latter the infiltrating masses, mostly degenerated, have been sur- 
rounded by a great number of concentric rings of connective tissue 
much resembling the rings seen around the vessels in myelomalacia 
(3), sub-acute combined cord degeneration (4) and similar condi- 
tions. The connective tissue rings in the latter are productive or 
reactive phenomena, provoked by the presence of a great mass of 
gitter cells which must be removed from the organism as useless 
and foreign bodies. The removal, as pointed out elsewhere (3), is 
accomplished by way of the perivascular spaces whence they are 
carried to, and drained by, the sub-arachnoid space of the spinal 
cord. The same process evidently obtains in the case of solitary 
tubercles of the spinal cord. Here the foreign, useless elements are 



SOLITARY TUBERCLE OF THE SPINAL CORD 175 

not gitter cells, but tubercle bacilli 3 which provoke the reactive ac- 
tivity of the tissue as well as of blood elements. The former results 
in proliferation of the adventitial elements and connective tissue 
ring formation, the latter in a dense accumulation within these rings, 
or, which is the same thing, within the changed adventitial spaces. 
Thence they are shipped like any other foreign substance to the 
meningeal subarachnoid space where they provoke reactive phe- 
nomena in the form of a meningitis. The latter, thus, is not the re- 
sult of the direct invasion of the meninges by the tubercle bacillus, 
as commonly thought (Bruns (5), Schmaus (6)), but is the result 
of the flow of the infected tissue fluids from the spinal cord towards 
the subarachnoid space. Such a mode of invasion of the meninges 
in the case under discussion is much more probable than a direct 
invasion, for as Fig. 2 shows, the tubercle is separated from the 
meninges by a zone devoid of tuberculous masses. 

The flow of contaminated tissue fluids from the adventitial spaces 
away from the cord is at least partially responsible for the lack of 
inflammatory phenomena in the areas adjacent to the tubercle. The 

The conclusions that might be drawn from the pathologic study 
of this case are as follows: 

1. A solitary tubercle of the spinal cord is the outcome of a 
local inflammation of the tissues brought on by a specific micro- 
organism. 

2. The inflammation provokes reactive phenomena on the part 
of the surrounding tissue elements, causing proliferation of the ad- 
presence of powerful connective tissue and fibrous capsules around 
the tubercles is of course also largely instrumental in protecting the 
rest of the cord against the spread of the infection within its tissues, 
ventitial cells and of hematogenous elements (lymphocytes, plasma 
cells, etc.). 

3. Both the tissue and hematogenous elements participate in the 
formation of the tubercle. 

4. Like any other useless and foreign body, the contents of the 
adventitial spaces are drained by the subarachnoid space. 

5. Landed in the latter, they provoke various inflammatory re- 
active phenomena on the part of the pia arachnoid, producing a 
meningitis. 

6. The latter is a secondary process, and not due to direct inva- 
sion of the meninges by the tubercle in the spinal cord. 

7. The draining of the disintegrated material by the subarach- 

8 Tubercle bacilli could not be found in the specimens of this case. 



176 W. TIIALHIMER AND G. B. HASSIN 

noid space as well as the powerful connective tissue rings around 
the tubercle are responsible for the preservation of the rest of the 
spinal cord and the absence of myelitis. 

REFERENCES 
i. Bassoe, Peter. Conglomerate Tubercle and Combined Degeneration of the 
Cord as Complications of Visceral Tuberculosis. Archives of Internal 
Medicine, XXI, 1918, 519. 

2. von Fieandt, H. Beitrage zur Kenntniss der Pathogenese und Histologic 

der experimentellen Meningeal- und Gehirntuberculose, Arbeiten aus 
dem. patholog. Institut der Universitat Helsingfors (Finland). III. 
235, 191 1 (Karger, Berlin). 

3. Bassoe, Peter, and Hassin, G. B. Myelitis and Myelomalacia, a Clinico- 

pathologic Study with Remarks on the Fate of the Gitter cells, Arch, 
of Neurol, and Psych., VI, 1921, p. 32. 

4. Hassin, G. B. Histopathologic Findings in Two Cases of Subacute (Com- 

bined) Cord Degeneration. Med. Rec. 1917, May 26th. 

5. Bruns, L. Die Geschwiilste des Nervensystems, Berlin, 1908. 

6. Schmaus, H. Vorlesungen iiber die pat'hologische Anatomie des Riicken- 

marks, Wiesbaden, 1901. 

7. Ayer, J. B. Puncture of the Cisterna Magna, Arch, of Neur. and Psych., 

November, 1920, Vol. IV, pp. 529-541. 

8. Wegeforth, Paul, Ayer, James B., and Essick, Charles R. The Method of 

Obtaining Cerebrospinal Fluid by Puncture of the Cisterna Magna 
(Cistern Puncture). American Journal of the Medical Sciences, June, 
1919, No. 6, vol. clvii, p. 789. 

APPENDIX 
Abstracts of Cases of Solitary Tubercle of the Spinal Cord, 

Collected from the Literature (Dr. Wm. Thalhimer) 

I have been able to find sixty-seven reported cases which appear 
to be definitely proved cases of solitary tubercle of the cord. Ab- 
stracts of fifty-eight of these are appended below. 

Herter in 1890 collected twenty-five cases. Schlesinger in 1898 
collected sixty-two cases. It may seem strange that Schlesinger 
'collected sixty-two cases in 1898, and we have been able to find only 
five more additional cases. The explanation probably is that Schles- 
inger's report included ten unpublished cases of his own and four- 
teen of his personal cases, only seven of which we could find. Also, 
Schift" and Gerhardt's titles indicate that each reported two cases. 
In both instances only one case was found to be that of a solitary 
spinal cord tubercle. Including the ten unpublished cases of Schles- 
inger, and the seven personal cases which we could not find, the 
total number of cases in the literature can be placed at eighty-four. 

Lebert (Handbuch der Prakt. Med., 1859) reports twelve cases. 
We do not know how many are his personal cases as this edition 
was not available, and later editions do not include this information. 

All abstracts are from original sources, except Eager's case, cited 



SOLITARY TUBERCLE OF THE SPINAL CORD 177 

from Gerhardt's Handbuch. The best articles are those of Herter, 
Schlesinger, Yeraguth and Brim, and Doerr. 

The following references were but partly available to us : 
Laurence, Gaz. Med., Paris, 1842 — No. 17. 
Foa, Giornale del. R. Accad. di Med. de Torino, 1910. 
Broadbent, Trans. Path. Soc. London, Vol. 8, 1881. 
Holz, Festschrift des Stuttgart. Arzt. Verein, 1897. 
Leyden, Klinik der Ruckenmarks, 1874. 
Hasse, Krank-Nervensystem 2nd. Ed. 1869. Virch. Handbuch. Ed. 

N. Bd. W S, 730. 
Larcher. Consid. sur Develop, des Tubercles — Inaug. Dissert., 1832. 
Bellecontre, These de Paris, 1876. 
Lebert. Handbuch der Prakt. Med., 1859. 

Although only eighty- four cases have been reported it will be seen 
that this lesion is not so uncommon but that it merits consideration 
in any case with the symptoms usually associated only with a primary 
neoplasm of the spinal cord. The similarity in the symptoms in all 
these cases is striking, as is also their sequence. It is hoped that 
this catalogue of the reported cases of solitary spinal cord tubercle 
will serve to draw attention to this condition. Early recognition 
and operative removal of the solitary tubercle offers the possibility 
of cure in some cases. 

Veraguth, 0., and Bruns, H. 

Case 1. " Subpialer, makrosopisch intramedullarer Solitartu- 
berkel in der Hohe des vierten und funf ten cervical segments ; Op- 
eration." Genesung, Cor.-Bl. f. Schweiz. Aerzte, 1910, XI, 1097; 
1147. 

Male, aged thirty-two years. Past history: Four years pre- 
viously patient developed pulmonary tuberculosis and a tubercu- 
lous abscess of the thumb. 

Present Illness: Stiffness and pain in nape of neck, greater on 
the left side, falling asleep of left, and then right arm, loss of power 
in left and right arms. Strange sensations and weakness of rest of 
body. 

Physical Examination: Pulmonary tuberculosis, vertebral col- 
umn negative on examination and x ray. The essential points of a 
careful neurological examination showed the follwing important 
fidings: marked sensory disturbances, anesthesia in left arm, loss 
of all control except a few finger movements, tendency to contrac- 
ture; fibrillary twitchings of muscles of left leg, marked weakness, 
sensory disturbances, less in right arm, with power diminished, as in 
left arm. Gait is that of a spastic hemiplegic. Left phrenic nerve 
paralyzed, and this was confirmed by x ray. Spinal fluid — clear, 



178 W. THALHIMER AND G. B. HASSIX 

showed a few lymphocytes, no globulin. Wassennann reaction 
negative. 

Operation: Laminectomy of second, third and fourth cervical 
vertebrae. At the level of the third cervical a diffuse globular 
swelling was found in the cord with increased consistency — no 
sharp demarcation. There was a yellow spot a few millimeters in 
diameter which was followed into the medulla, where a tumor was 
found which shelled out cleanly. The tumor measured 9.5 by 11.5 
by 17 mm. 

Diagnosis: Encapsulated solitary tubercle. Post-operative 
course: Patient slowly made a complete recovery and resumed occu- 
pation of telephone operator. 

Veraguth, 0., and Bruns, H. 

Case 2. Weiterer Beitrag zur Klinik und Chirurgie des intrame- 
dullaren Konglomerat tuberkels. Corresp. f. Schweiser Aerzte, 46: 
385-408 and 424-430, iqi6- 

A tuberculous thirty-six year old physician exhibited signs of 
Brown- Sequard and Horner syndromes preceded by spontaneous 
pain in the dorso-cervical region, pain and tremor in left hand. Two 
operations had been performed, and at both solitary tubercles have 
been located in the lower half of the cervical region of the spinal 
cord (one at the sixth and seventh cervical segments, another at the 
fifth cervical). The post mortem in addition showed tubercles in the 
pons, cortex, seventh and eighth cervical roots and the posterior 
horn of the fifth cervical segment. 

The authors claim that once it is possible to diagnose clinically a 
solitary tubercle and determine its exact localization, an operation 
should be recommended, provided the tubercles are not multiple. 

Richard Wagner. 

Zur Diagose des Solitar-tuberkels der Medulla spinalis, Zcitschr. 
f. Kinderh-eilkunde, 25: 322, 1020. (Originalien.) 

An epileptic mentally deficient fourteen year old boy entered the 
hospital complaining of severe headaches, vomiting, pain in the 
sacrum, right hip and knee joints. The right leg was adducted, 
flexed and markedly atrophied. There were clinical and serologic 
manifestations of a meningitis. The skin was covered with tuber- 
culous sores. The post mortem revealed miliary tuberculosis with 
involvement of the bronchial glands, lungs, liver, kidneys, conglom- 
erate tubercles of the upper lobes of the lungs, corpus striatum, cere- 
bellum and of the lower lumbar region of the spinal cord. 

Zunker. 

Tuberkel in der grauen Substanz der Lendenanschwellung, mit 
Verlust der Schmerzempfindung, Zeit. f. Klin. Med., I, 1880, 375. 

Male, age 31. Amputation of right leg for tuberculosis and 
complications. Neurological examination five weeks after amputa- 
tion: positive findings confined to lower extremities. Complete 
flaccid paralysis of stump of right leg and entire left leg. Muscles 
irritable and contract on stimulation. Tendon reflexes not increased. 



SOLITARY TUBERCLE 01' THE SPINAL CORD 179 

Loss of sensation on both sides up to inguinal fold. Temperature 
missing over same area, urinary and rectal incontinence. Pre-lethal 
recovery of power of movement in stump of right leg. 

Autopsy: Tuberculosis of lungs, liver, spleen, kidney and brain. 

Cord: In the upper lumbar portion a round, three cm. long, 
bean sized tubercle replaces the gray matter. Microscopical report 
not given. 

de Jonge, Dr. 

Tumor der Medulla Oblongata ; Diabetes Mellitus, Arch f. Psych 
u. Nerv., XIII, 1882, 658. 

Male, age thirty-seven. 

Three months ago cough, expectoration, pain in chest. Five 
weeks ago edema, ascites, chronic lung process, no neurological signs. 
no glycosuria. Later, absence of edema, ascites. Then, polydipsia, 
polyuria, glycosuria and finally, sudden right hemiplegia and coma. 
Course fatal four months after admission. 

Autopsy: Brain — petechiae in medulla, otherwise negative. Me- 
dulla oblongata — a circumscribed, caseous tubercle, 15x7x5 mm. 
extending from lowest part of olive down to origin of first cervical 
nerve in the posterior horn. Tuberculosis of lungs, bronchial and 
mesenteric nodes. 

Sachs, B. 

" A Contribution to the Study of Tumors of the Spinal Cord." 
Journal of Nervous and Mental Disease, XIII, 1886, 647. 

Male, aged thirty-two years. 
• Present illness: Four weeks prior pains in left shoulder, then 
left arm. Weakness of hand past week, skin puffy and glossy. 

Physical Examination: Hyperesthesia and puffiness of left 
fingers and weakness of left hand, slight loss of power in arm; fore- 
arm and shoulder remain unchanged. Slight paresis, hyperesthesia 
of left leg and knee jerk, increased ankle clonus. After seven 
weeks, changed from unilateral to bilateral, complete paraplegia of 
lower extremities, abdominal respiratory movements and right upper 
extremity also paralyzed, incontinence of urine. Sensory: Gen- 
eral hyperesthesia of left side below level of third rib, then anes- 
thesia. Anesthesia of right leg, trunk and right arm. 

Autopsy: Tumor, hazel nut size, at level of sixth and seventh 
cervical vertebrae but adherent to meninges, with a caseous center 
and hard cortex which takes up the entire anteroposterior thickness 
of cord. Few small tuberculous deposits in pia in mid dorsal region. 
Myelitis above and below tubercle, no degeneration below area of 
myelitis. Solitary tubercle of cord, pulmonary and intestinal tuber- 
culosis, general miliary tuberculosis. 

Marfan. 

Tubercle Solitaire de la Moelle siegant au niveau des deuxibme 
et troisieme paires sacrees. Semainc Mcdicale, XVII , 189J, 92. 

Male, aged three years. Sudden spastic, incomplete paraplegia 
at twenty-six months. Fxaggerated knee jerks, slight muscular 



180 W. THALHIMER AND G. B. HASSIN 

atrophy, cyanosis of extremities, no pain or sensory disturbances, 
gluted bed sores, retention of urine. Fatal. 

Autopsy: Solitary tubercle at the level of the emergence of the 
two to three sacral nerves. 

Aniel Rabot. 

Tubercule Primitif de la Moelle: Meningite Tuberculeuse Se- 
condare, Tuberculose, Concomitante des Ganglions Bronchiques 
de la Pleure, du Poumon, du Foie, de la Rate et du Rein Droit. 
Lyon Medical, LXXXVIII, 1898, 605. 

Male, aged nine months. Paralysis of left leg, and diarrhea. 
Symptoms of meningeal irritation. Left leg flexed and adducted, 
shortened, atrophy and loss of power, no loss of sensation. 

Autopsy: Basilar meningitis. The left side of the lumbar en- 
largement is occupied by a mass of tuberculous tissue with caseous 
center; easily enucleated. Tuberculosis of lungs, pleura, spleen, 
liver and right kidney. 

Gouraud, F. 

Tubercule de la Moelle Epiniere, Bull. Soc. Anat. de Paris, 1902. 

Male, aged twenty-six. Advanced pulmonary tuberculosis, pain 
and weakness in left leg, followed by complete paraplegia. Reflexes 
normal, marked sensory disturbances, incontinence of urine and 
feces. 

Autopsy: Pulmonary and renal tuberculosis. The brain showed 
quiescent tubercles in various places. In the cord, 9 cm. above 
conus, a caseous tubercle 1 cm. in diameter was found replacing the 
left posterior portion. 

Hunter, W. K. 

" Case of Tubercular Tumour of the Spinal Cord in a Child Two 
Years Old." Brain, XXV, 1902, 226. 

Male, aged two years. Internal strabismus of right eye, head 
turned to left and somewhat rigid. Right arm shows complete 
flaccid paralysis. Right leg shows no voluntary movement and 
slight rigidity. Left leg has slight movement. Knee jerks exag- 
gerated, right greater than left, bilateral ankle clonus, plantar reflex 
absent. Disturbed sensation over arms, trunk and legs. 

Autopsy: Pulmonary tuberculosis, tuberculous meningitis. In 
the cervical cord, extending from the second to the seventh cervical 
vertebra, is a caseous nodule 1^x3 cm. in size. 

Luce. 

Ueber Tuberkulose des Zentralnervensy stems (Case reported 
before the Biologische Abtheilung des drztlichen Vereins, Ham- 
burg, Feb. 17, 1908), Munch, mod. Woch., 1908. 

Male, aged twenty-two years. Cough and expectoration ; pain, 
then paralysis of left foot followed by paralysis of right leg and re- 
tention of urine. 

Physical examination : Advanced pulmonary tuberculosis, flaccid 
paralysis of both legs, with total analgesia for touch and temperature 



SOLITARY TUBERCLE OF THE SPINAL CORD 181 

of both legs. Patellar reflexes increased on both sides, ankle jerks 
absent, Babinski present on right, absent on left. 

Autopsy: Pulmonary tuberculosis, tuberculosis of mesenteric 
lymph nodes, and perforation peritonitis, tuberculosis of spleen. 
Solitary tubercle in meninges over left parietal lobe. Solitary 
tubercle in center of cord extending from ninth dorsal to first lum- 
bar vertebrae, tubercle bacilli found. 

Kolitz. 

Ucbcr Riickcnniarkstumoren int Kindcsaltcr, Wien mcd. Blatter, 
1885. Nr. 42, 1274. 

Case 1. Female, aged one and a half years. 

Family history: Mother has tuberculosis. Two brothers died of 
tuberculosis. Past history — treated for lues. Present illness, tuber- 
culous meningitis, paralysis of left leg. 

Autopsy: Tuberculous meningitis. Cord at the level of the 
sixth and seventh dorsal vertebrae is softened and widened. A 10 x 9 
mm. tumor in left side of cord, with caseous center, cortex trans- 
parent, slightly red, studded with small nodules. The tubercle re- 
places and compresses almost the entire diameter of the cord. 

Case 2. Female, aged five and a half years. 

Scarlet fever complicated by acute nephritis, cervical adenitis 
Pulse irregular, slow, later very rapid, Respiration rapid. Edema, 
anasarca, hyperesthesia of skin very marked. Rigidity of neck one 
day ante mortem. No motor or reflex disturbances except reten- 
tion of urine. 

Autopsy: Miliary tuberculosis of most organs, tuberculous men- 
ingitis. Cord: (1). Tumor 5x3^x4 mm. between dorsal and 
lumbar regions size of a lentil. (2) Tumor 10 mm. below this, i l / 2 
mm. in diameter, round. Microscopical report not satisfactory. 

Remarks: Acute tuberculosis complicated the exanthem. 
Strange that patient had no motor symptoms. 

Gerhardt, C. 

Zwei Fallc von Ruckcnmarksgeschwulstcn, Charite- Annul en. 
XX, 1893, 162. 

Male, aged thirty-eight years. Pulmonary- tuberculosis, paresis 
of left shoulder, arm and leg. Active reflexes of left side, sensa- 
tion diminished on right side below third rib. Complains of cold- 
ness and deafness on right side. Cranial nerves: left palpebral 
fissure narrower, left angle of mouth elevated, uvula pulled to 
right, tongue pulled to left. Pains in left arm and neck. Course 
fatal four months after onset of neurological symptoms. 

Autopsy: Pulmonary tuberculosis of lungs, liver, prostate, 
kidney, spleen and epididymis. Solitary tubercle in occipital lobe 
of brain. Tubercle in cervical swelling of cord occupying almost 
entire diameter. 

Obolonsky. 

Ueber cinen Fall von Reuckcnmarkstuberculose mit Verbreitung 
des tubcrculosen Processes auf dem Wege des Centralcanales. Zeit. 
f. Heilkunde, IX, 1888, 411. 



182 W. THALHIMER AXD G. B. HASSIN 

Male, aged one and a half years. 

Clinical diagnosis: Paralysis of left abdominal parietes, paresis 
of both lower extremities, chronic enteritis, catarrhal bronchitis, bi- 
lateral bronchopneumonia. 

Autopsy: Chronic tuberculosis of peribronchial, mesenteric and 
inguinal nodes, right lung, pleura, peritoneum, intestines and rectum, 
heart, left kidney and spinal cord. 

At the dorso-lumbar junction there is a nodule, egg shaped 20x9, 
cavity in center, complete diameter of cord occuppied. Meninges 
normal. 

Microscopical examination: Typical tubercle with caseous cen- 
ter, miliary tubercles on periphery, tubercle bacilli found. 

Remarks: Small tuberculous miliary nodules were found in the 
central canal some distance away from the large tubercle. Since 
there was hydromyelia associated, and since the larger tubercle ap- 
peared older, Obolonsky believes that central canal acted as the 
mode of dissemination of tuberculosis. 

Schiff, Arthur. 

Ueber zwei Falls von intrameditllarcn Riickenmarkstumoren, 
Obersteiner' s Arbeiten aus dem Institut fiir Anatomic und Physio- 
logic, 2, 1894, 155. Intramedullares Tuber kel des Riickcnmarks. 

Symptoms: Motor and sensory paraplegia of lower extremi- 
ties, bladder disturbances. Clinical diagnosis, compression myelitis. 

Autopsy: Caries of vertebra, compression myelitis, pulmonary 
tuberculosis. In cervical cord unexpectedly there was found a 
tubercle, spherical, diameter .5 cm. in right half of cord replacing 
almost entire half, very little external change. Microscopical ex- 
amination: Caseous center, round cell infiltration in perivascular 
lymph spaces. 

Sudek, P. 

Ein Fall von Tuberkelbildung im Riickenmark, Jahrbilcher der 
Hamburgschen Staatskrankenanstalten, Bd. IV, 1893-4, 58. 

Male, aged thirty-four years. Pulmonary and laryngeal tuber- 
culosis, paraplegia, occasional involuntary contractures, diminished 
touch and pain sensation in both legs, also pains and formication, 
slightly diminished sensation in both thighs. Hyperesthesia marked 
over distribution of first lumbar nerve. No sensory disturbances of 
genitals, superficial and deep reflexes of lower extremities, increased 
ankle clonus. Other reflexes normal, normal electrical reaction, no 
bladder disturbances, first lumbar vertebra tender to percussion. 
Course nine months. 

Autopsy: Tuberculosis of lungs, larynx and intestines. Spine 
and meninges negative. Cord : Upper lumbar, pea sized, yellowish 
gray, caseous nodule. Microscopical examination : Typical tuber- 
culosis with tubercle bacilli. 



SOLITARY TUBERCLE OF THE SPINAL CORD 183 

Habershon, S. 0. 

Clinical cases ; paraplegia ; strumous tumor in spinal cord ; hy- 
peresthesia ; phthisis, strumous disease of uterus, Guy's Hospital 
Reports, 1872. 

Female, aged twenty-eight years. Past history, pneumonia three 
times, with pleurisy. Present illness, (1) Menorrhagia. (2) Ach- 
ing pains in legs, more in right than left leg. (3) Numbness of sen- 
sation of pins and needles. (4) Finally complete paraplegia. 
Course: Muscles firm, reflexes easily induced, paralysis of sphinc- 
ters, steady loss of motion and sensation in lower extremities, hyper- 
esthesia of surface of legs, bed sore of sacrum opening into spinal 
canal, erysipelas at site of bed sore. 

Autopsy: Round tubercle (cherry size) in lower part of dorsal 
cord, replacing nervous tissue, homogeneous, avascular, greenish 
yellow. Tuberculous lungs, intestines and uterus. 

Chvostek. 

Zzvei Fdllc von Tubcrkulosc des Ri'ickcnmarkes, Wicn. med. 
Presse, XIV, 1873, 810. 

Case 1. Male, aged thirty years. Drawing and dragging pains 
and muscular twitching; then paralysis, hyperesthesia, anesthesia 
and analgesia of left lower extremity. Right lower extremity like- 
wise soon involved. Bladder paresis, spleen enlarged, lungs nega- 
tive. Course: Death seven weeks after onset. 

Clinical diagnosis: Acute myelitis. 

Autopsy: Pea sized, hard, yellow nodule in lower thoracic re- 
gion, with myelitis in vicinity. Pulmonary tuberculosis with bron- 
chiectasis in left lung. 

Case 2. Male, aged forty-three years. Disturbances in sensa- 
tion and motion in left upper extremity, then left lower extremity, 
then right lower extremity, followed by rectal disturbances. Right 
upper extremity involvement, vesical disturbances, sexual functions 
and finally dysphagia. Sensory disturbances of extremities and 
later of trunk, pains in bones of extremities, girdle sensation (?). 
Reflexes not increased; paralysis of extremities and later trunk 
muscles (tonic), cramps in muscles, including neck muscles. Course 
eight months. 

Autopsy: Cord — At the fourth and fifth cervical vertebrae there 
is a hazel nut sized tubercle,, circumscribed, easily enucleated, soft, 
grayish yellow, caseous, with hemp seed sized cavity in center. Sur- 
rounding myelomalacia in left anterior horn ascending. Lungs, 
ileum and kidney show tuberculosis. 

Mueller, L. R. 

Ueber einen Fall von Tuberculose des obcren Lendenmarkes in it 
besonderer Beriicksichtigung der secunddren Degenerationen, 
Deutsch. Zeit. f. Nerv., X, 1896-7, 273. 

Case 1. Female, aged forty years. Three years previous there 
were sharp pains in the extremities. Patient was in bed for one 
and a half years, after which pains disappeared, and patient could 
get about. One half year after this exacerbation with sensory dis- 



184 W. THALHIMER AND G. B. HASSIX 

turbances, no pains in lower extremities but sharp pains in upper 
extremities. For the past six months loss of abdominal sensation, 
vesical and rectal disturbances, diminished voluntary control of 
lower extremities, involuntary movements and twitchings in lower 
extremities. 

Physical examination: General kyphosis. Motor paraplegia, 
contractures of lower extremities, disturbed sensation below um- 
bilicus, knee jerks and ankle jerks present, no ankle clonus. Bab- 
inski present. 

Autopsy: Thickening of dura between the fourth cervical and 
second dorsal vertebrae. At the level of the first and second lumbar 
vertebrae, >4 cm. deep in the cord, there is a spindle-shaped tumor 
1^2 x i cm. in size. 

Microscopical examination: Tumor showed typical caseation and 
tuberculous granulation tissue. 

Case 2. Male, aged forty-six years. Weakness of legs, reten- 
tion of urine and bladder pains. 

Physical examination: Definite signs of advanced pulmonary 
tuberculosis, gait is laborious but progress is possible, drags right 
foot. Active motion of right lower extremity and dorsiflexion of 
foot is impossible. Patellar reflexes, right greater than left, ankle 
jerks absent on both sides, cremasteric reflexes unequal. Abdominal 
reflexes, right absent, left weak. Pain and temperature sensation 
lost in the left lower extremity. 

Autopsy: Bilateral pulmonary tuberculosis. A rounded mass i 
cm. in diameter is present in the cord at the level of the second 
thoracic vertebra. It is situated on the right side of the cord and 
only a small area of cord substance is left around the tumor on the 
left half. It is grayish and yellowish and distinct from the surround- 
ing tissue. 

Microscopical examination: A structureless mass, caseous in 
some areas, no giant cells, no tubercle bacilli demonstrated, tubercu- 
lous granulation tissue surrounding this. Diagnosis: Tubercle. 

Oberndorffer, Ernest. 

Ein Fall von Riickenmarkstubcrkcl, Munch, mcd. Woch., LI, 
1904, 108. 

Male, aged twenty-six years. Constipation and difficulty in 
voiding for two and a half months. Progressive weakness in left 
leg and severe pains in abdomen. Paralysis of both legs, sensory 
disturbances on left side of body between the costal margin and 
ileum. Reflexes of lower extremities first exaggerated and then 
lost. 

Autopsy: At the level of the eighth to ninth dorsal vertebrae 
there is a yellowish white tumor occupying most of the cross section 
of the cord 1.3X.5 cm. in size. 

Microscopical examination: Conglomerate tubercle with caseous 
center, surrounded by many recent tubercles. In the periphery are 
many giant cells and tubercle bacilli. 



SOLITARY TUBERCLE OF THE SPINAL CORD 185 

Schultz, Friedrich. 

Zur Symptomatologie and pathologischcn Anatomic dcr taber- 
culosen und cntsiindlichen Erkrankungcn mid der Tubcrkel des cere- 
brospinalen Nerverisystems. Dent. Arch. f. klin. Med., XXV, 1880, 
297. 

Clinical diagnosis: Ileo-typhus. No headache or paralysis. 

Autopsy: Miliar}' tuberculosis of lungs, liver, kidney and spleen. 
Tubercles (cherry stone size) in pia, dura and brain. Cord, dorsal 
region ; in left lateral column a pea sized tubercle with caseous cen- 
ter, surrounded by round cell infiltration. 

Elsberg, C. A. 

"Laminectomy and Removal of Conglomerate Tubercle from 
the Substance of the Spinal Cord." Annals of Surgery, 1917, LV, 
269. 

Symptoms : (1) Loss of power in lower extremities. (2) Blad- 
der and rectal disturbances. (3) Severe pain in lower abdomen. 
Operation: Removal of arches of ninth, tenth and eleventh dorsal 
vertebrae. Pathological findings: Small tumor ij^xi cm. in sub- 
stance of cord. Microscopical examination: Tuberculoma. Pos- 
terior root section three months after on account of spastic para- 
plegia. Result: Two years after operation marked improvement, 
patient regained control of bladder, walks around without support. 

Bellange, G. 

Note sur un Cas de Tubercule dc la Moelle £piniere, L'Encc- 
phale, 1885. 

Male, aged thirty-six years. Left lower monoplegia with loss 
of reflexes, pains and temperature absent or disturbed in parts of 
left leg, touch almost intact. Ataxia, complete disorientation, gen- 
eral weakness, signs of pulmonary tuberculosis and cough. 

Autopsy: Brain negative. Pulmonary tuberculosis. Cord; Up- 
per lumbar region shows a tumor. Microscopical examination ; in 
posterior half of left lateral column caseation, little secondary de- 
generation. Diagnosis ; Tubercle. 

Schlesinger, Herman. 

Case 1. Female, aged twelve years. 

Sudden onset, paresis of lower extremities, vesical disturbances, 
paralysis of right upper extremity, diminished sensation below um- 
bilicus, greatly disturbed deep sensations, flaccid paraplegia, loss of 
knee jerks and ankle jerks, incontinence of urine and feces, chorei- 
form movements. Course ten weeks. 

Autopsy: Multiple tubercles in brain and brain stem. Meninges 
covered with gray exudate, solitary tubercle at level of fourth to 
sixth and eighth thoracic vertebrae and in upper lumbar region. 

Microscopical examination : Typical caseation and giant cells. 

Case 2. Female, aged thirty-five years. 

Pains and contractures in left arm, paresis in both legs, incon- 
tinence of urine and feces, muscular atrophy of left upper extremity. 



186 W. THALHIMER AND G. B. HASSIX 

increased tendon reflexes of lower extremities. Course eight 
months. 

Autopsy: Tuberculosis of lungs, pleura, kidney and liver, soli- 
tary tubercle in right occipital lobe, solitary tubercle at lower end of 
cervical swelling of cord. It occupies the left half and is a round, 
caseous tumor, the size of a small nut. 

Case 3. Female, aged sixty-two years. 

Clinical diagnosis: Tumor of spinal medulla. History not given. 

Autopsy: In the left side of the cervical cord, at the level of the 
fifth to sixth cervical vertebrae there is a caseous mass 2^4 mm. in 
diameter. 

Diagnosis: Tubercle of the cord. 

Case 4. Male, aged sixty-six years. 

No clinical history, only autopsy findings obtained. 

Autopsy: Chronic peri-encephalitis and atrophy of brain, chronic 
internal hydrocephalus. A pea sized solitary tubercle with central 
caseation found in the cord at the level of the fifth to sixth thoracic 
nerves. 

Case 5. Male, aged thirty-nine years. 

Clinical diagnosis: Myelomeningitis, no further data obtained. 

Autopsy: Pulmonary tuberculosis^ tuberculous meningitis, tu 
bercle in the optic thalamus, solitary tubercle at the level of the sec- 
ond to third lumbar vertebrae, replacing most of the cord. 

Case 6. Male, aged fourteen years. 

Pains and rigidity of neck for months, atrophy of muscles of 
left shoulder girdle and hand. Hyperesthesia of entire body, reten- 
tion of urine. Course three months. 

Autopsy: Spondylitis of fourth cervical vertebra, cerebral and 
spinal tuberculous meningitis. Central caseous tubercle of the cord 
at the level of the sixth cervical vertebra. 

Schlesinger, Herman. 

Ueber Zentrale Tuberculose des Rilckenmarkes. Dcutsch. Zeit. 
f. Nerv., VIII, 1895-6, 398. 

Male, aged forty-two years. Onset ten weeks ago with dizziness, 
regurgitation of fluids through the nose change in speech, difficulty 
in swallowing, pain in right side of face, pains and paresthesia in 
both upper extremities. For four weeks weakness of both upper 
extremities and right lower extremity ; for the last week, urinary 
incontinence. 

Physical examination: Infiltration of both apices of the lungs, 
palsy o.f soft palate. Vocal cords inflamed and show slight paraly- 
sis, rigidity and tenderness of neck, upper extremities show bilateral 
muscular atrophy, the right greater than the left. Ataxia, weak- 
ness of shoulder and back muscles, the accessory muscles used in 
respiration. Lower extremities show diminished strength, more in 
right than left, sensory disturbance, ulnar side of right hand shows 
diminished touch and pain sensation;. Ring of temperature, hyper- 
esthesia about neck, paresthesia to temperature below this. Left 
leg shows almost complete loss of temperature sensation on exten- 



SOLITARY TUBERCLE OF THE SPINAL CORD 187 

sor surface and loss of epicritic temperature sensation on flexor sur- 
face. Diminished sensation for passive motion in joints of upper 
extremities. Reflexes: Patellar exaggerated on both sides and bi- 
lateral ankle clonus present. Abdominal reflexes absent, cremas- 
teric diminished, mentality clear. 

Autopsy: Chronic, bilateral pulmonary tuberculosis with pleurisy 
of left side tumor of cervical cord at level of second to third cervi- 
cal vertebrae. This is a circumscribed, homogeneous mass, sur- 
sounded by a rim of granulation tissue rich in giant cells. 

Observation : The central origin of the tubercle in the gray sub- 
stance of the cord is indicated by the symptom-complex. 

Mader. 

Ein Fall von Tuberkulose des Halsmarkcs, Wiener, medicinische 
Presse, XX, 1879, io 5^- 

Male, aged twenty-nine years. Symptoms: 1. Spastic para- 
plegia and pains, severe cramps in legs. 2. Later, coughts, sweats, 
hoarseness. 3. Prelethal right hemiplegia. Physical examination: 
Knee jerks exaggerated. Voluntary motion reduced to minimum, 
diminished sensation in extremities and half way up trunk. Tem- 
perature sensation normal, hyperesthesia in upper half of trunk and 
upper extremities. Course one and a half years. 

Autopsy: 1. Pulmonary tuberculosis of lungs with cavities. 2. 
Recent tubercles in lower part of ileum. Cord, level of seventh 
cervical vertebra is studded with yellow masses in posterior part of 
cord. Area of softening immediately below this, another in lower 
part of thoracic region. 

Serre. 

Observations et reflexions sur I'etat dc nos connaissances a 
I'egard de quelqucs lesions organiques, Gas. Med. de Paris, 1830, 
Tome, No. 7, 57. 

Male, aged forty years. " Sudden loss of perspiration." Pains 
in lumbar region and hypogastric region. Retention of urine. 
Paraplegia, numbness of lower extremities. 

Autopsy: Pleural adhesions, hepatization of lungs, vertebra and 
membranes normal. Cord at level of fourth and fifth lumbar ver- 
tebrae: The entire width of cord is replaced by a "rosary" of 
large yellow tubercles. 

Gull, W. 

"Case of Paraplegia," Guy's Hospital Reports, 1858. 

Age of patient eight months. Paresis of right and lelt arms, 
rigid neck, retracted head. Atrophy of muscles of right and left 
arms for two and a half months and spastic contractures. Course 
fatal in seven months. 

Autopsy: In the lower part of the cervical swelling is a tubercle 
replacing the cord tissue. 

Eisenschitz, J. 

Tuberkel des Riickenmarks. Jahrb. fiir Kinderheilkunde, 1870, 
224. 



188 W. THALHIMER AND G. B. HASSIN 

Male, three and a half years old. Headache, loss of appetite, 
sleeplessness, both lower extremities paralyzed. In twenty-four 
hours sudden incontinence of urine. Six weeks later same symp- 
toms and analgesia below the level of the eighth dorsal, front and 
back, no anesthesia. Hyperesthesia above eighth dorsal. Reflexes 
active in paralyzed lower limbs, occasional convulsive movements. 

Autopsy: Milky thickened pia at base of brain, with small 
nodules matted together in places. Two caseous nodules in right 
lobe of cerebellum. Cord at lower level of dorsal region a yellow, 
caseus nodule, the size of a pea. Tuberculosis of bronchial nodes,, 
lungs, intestines, spleen, liver and kidney. 

Eager. 

In Gerhardt's Handbuch der Kinderkrankheiten, Bd. V., Koht's 
Tumoren des Ruckcnmarks, 420, Gottschalk's Sammlung, 1838. 

Male, aged thirteen years. One year previously left cephalalgia, 
stammering pains, in left side neck. Pains followed first by weak- 
ness, and then paralysis of right leg and arm. Slight decrease in 
sensation in paralyzed limbs, burning pains in joints of affected 
limbs. Six months prior, cough, expectoration, dyspenea, right facial 
palsy, pains and contractios of muscles of neck, and of right limbs, 
itching, burning pains from the neck to the foot on right side. 

Autopsy: Two and one half inches below pons there is an area 
of softening in which are two bodies, round, yellowish green, with 
gross appearance of tubercles. The vicinity is perfectly normal in 
appearance and consistence. 

Ollivier. 

Maladies de la Moelle flpinicre, vol. 2, 1837. 

Case 2. Female, aged twenty-four years. Convulsive move- 
ments of extremities three days before death, especially the right 
side. Incontinence, contracture of upper extremities, sensation pre- 
served. Few hours ante-mortem there was paralysis of right arm. 
Physical signs of pulmonary tuberculosis. 

Autopsy: Brain, negative. Cord: In the lower part of spinal 
medulla below the pyramidal eminences and olives there is a round 
pea sized body circumscribed and encysted, a tubercle, opaque and 
yellowish white. 

Case 2. Male, aged sixty-three years. Died of pneumonia, had 
given history of epileptiform attacks for fifty years. 

Autopsy: Negative except for two tubercles of the spinal cord, 
the size of hazel nuts, adherent, encapsulated. Vicinity normal in 
appearance. 

Case 3. Female, aged . Nervous phenomena at 

each menstration, globus hystericus. Meningitis which was fatal. 

Autopsy: Basilar meningitis, spinal medulla shows a nut sized 
tumor, hard and rilled with tuberculous, softened material. Pul- 
monary tuberculosis with cavities. 

Case 4. Male, age unknown. Epilepsy since infancy. Acute 
meningitis, which was survived, followed by weakness and right 
hemiplegia. Died in course of delirium. 



SOLITARY TUBERCLE OF THE SPINAL CORD 189 

Autopsy: Brain and meninges, negative. Cord: Between the 
first and seveth vertebrae the cord is softened. In the midst of the 
softening there is an elongated tubercle, encapsulated and caseous. 
Other organs negative. 

Case 5. Male, aged fifty- four years. 

Past history: Hip disease, followed by ankylosis. Present ill- 
ness: Lumbar pains. There is a soft tumor just beneath the in- 
ferior angle of the left scapula. Pain and numbness in the left arm, 
constipation, tenesmus and incontinence, loss of power and sensation 
of lower extremities, but some temperature sensation retained, re- 
tention of urine. Ataxia, convulsive movements of lower extremi- 
ties, bed sores. 

Autopsy: Brain and meninges, negative. External to the lum- 
bar portion of the dura, white, caseous plaques, which can easily be 
raised off. Between the twelfth dorsal and first lumbar there is a 
tubercle, the size of an olive. No surrounding changes. Vertebrae 
normal. In the vertebral gutters there is pus (explains tumor be- 
'ow scapula). 

LeBoeuf. 

Tubercule de la Moelle £pinicrc. Journal de Medccine, dc Chir- 
urgie et de Pharrn. 97, 1895, 401. 

Male, aged thirty-nine years. Pulmonary and laryngeal tuber- 
culosis. 

Central nervous system. Paresis of right side of body ; sensa- 
tion, including deep sensation, diminished. Tingling, then pains of 
right extremities, spasticity of right side, temporary ptosis of right 
lid, right nystagmus, right pupil dilated, tongue turned toward 
right, no vertebral tenderness, no visceral reflex disturbances. 

Autopsy: Pulmonary and laryngeal tuberculosis. Central ner- 
vous system — Macroscopic tubercle in upper part of cervical cord 
and lower part of spinal medulla, in gray substance of right half of 
cord just anterior to the posterior commissure, occupying the pos- 
terior part of the central gray substance. Microscopical examina- 
tion : Tubercle, caseous center. 

Chiari. 

Demonstration von Ri'tckenmarktstuberkcl in W andcrvcrsamm- 
lung des Vereins fi'tr Psychiatrie in Wien. Neurol. Zcntrabl, Oct. 
1895. No case histories. Demonstration of specimens which were 
discovered post mortem and caused no symptoms ante mortem. 

Jolly. 

Ueber tuberkulose Riickcnmarkscrkrankungcn (Report of case 
before the Gesellschaft der Charite-Aerzte in Berlin). Mucnchener 
medisinische Wociicnschrift. vol. 49, 1902, p. 2026. 

Symptoms: d) Flaccid paralysis. (2) Muscular atrophy. 
(3) Reaction of degeneration, tendon reflexes retained, symptom 
would come and go suddenly. Jolly demonstrated specimen of soli- 
tan- tubercle from substance of cord at level of second lumbar ver- 
tebra. 



190 W. THALHIMER AND G. B. HASSIX 

Rystedt, G. 

Ucbcr cinen Fall von Solitartuberkel im Riickenmark mit Neben- 
befund von sogenannter artifisieller Heterotopic desselben, Zeit. f 
klin. Med., LXIII, 1907, 220. 

Male, aged twenty-five years. Hoarseness, paresis of right leg, 
pulmonary tuberculosis and tuberculous meningitis, paralysis of ab- 
dominal muscles. Abdominal reflexes absent on left, weak on right, 
cremasteric, and anal reflexes absent. Lower, extremities show 
spastic paraplegia, more marked in right leg. Knee jerks sluggish, 
ankle jeks equal on both sides. Bilateral Babinski, no ankle clonus. 
Dissociation of sensation as high as tenth dorsal vertebra. Course 
two and a half months. 

Autopsy: Pulmonary tuberculosis, tubercle of cord at the level 
of the fifth dorsal vertebra, 24x8 mm., sharply demarcated with 
central caseation, periphery of this rich in giant cells and tubercle 
bacilli. 

Thorel, Ch. 

Grosser Solitartuberkel des Ruckenmarks. Deut. med. Woch. 
XXXIII, 1907. 216. Demonstration of specimen before Aerztlicher 
Verein in Nurnberg, Nov. 21, 1907. 

Female, aged thirty-one years. Autopsy: In cervical cord 13 
cm. below the fourth ventricle there is a nacrotic solitary tubercle 
the size of a pigeon's egg. Tubercle bacilli could not be demon- 
strated. Patient died of advanced pulmonary tuberculosis. Other 
clinical or microscopical facts not given. 

Mohr, R. 

Ucber einen Fall von Tuberkulosa des Lendenmarks, Vcrhand. 
d. Dcutsch. Path. Gesellschaft, Zentral Bd. f. allg. path. Anat., 1909. 

Male, aged twenty years. Cough, enlarged lymph nodes, pains 
in back and lower extremities. Paresis of lower extremities, bladder 
disturbances. Left lung showed tuberculosis. Flaccid paralysis of 
both lower extremities, knee jerks, ankle jerks and plantar reflexes 
increased. Sensation lost below the knees. 

Autopsy: Generalized tuberculosis. The lumbar enlargement is 
abnormally large and shows central caseation. Microscopical exam- 
ination showed a conglomerate tubercle. 

Doerr, Carl. 

. Zur Kenntnis der Tuberkulose des Ruckenmarks. Arch.f. Psvch. 
IL, 1911-12, 406. 

Case 1. Male, aged eleven years. Sudden onset with headache 
and fever. Presented picture of meningitis or typhoid, was delir- 
ious and unconscious. Slight nystagmus, ptosis of left eye. slight 
left abducens, paralysis. Physical examination otherwise negative. 
Course fatal in a few days. 

Autopsy: Generalized miliary tuberculosis, tuberculosis of men- 
inges of cord and purulent exudate at base of brain. Pea sized 
tubercles in left cerebral hemisphere, a pea sized nodule in the cer- 



SOLITARY TUBERCLE OF THE SPINAL CORD 191 

vical cord more confined to the gray substance, with the consistency 
increased. 

Case 2. Male, aged twenty-two years. Pains in right knee fol- 
lowed by weakness and atrophy of right leg, then by cramps and 
paralysis. Finally, paralysis of left leg and atrophy, incontinence 
of urine and feces. Course fatal in two and a half months. Di- 
minished power in right arm, bilateral paralysis and atrophy of both 
lower extremities. Sensation lost in right lower extremity, dimin- 
ished in left. Knee jerks, ankle jerks and ankle clonus absent on 
both sides. 

Autopsy: In the lower cervical and upper thoracic cord there is 
a circumscribed tubercle 9 mm. in diameter. 

Microscopical examination: Typical tubercle, extensive tubercu- 
losis in lungs, pericarditis, and tuberculosis of right knee. 

Hayem, George. 

Observation pour serrir a I'histoire des tubercnles de la moelle 
epiniere, Arch, de Phys. norm, et path., V, 1873, 431. 

Male, aged thirty-seven years. Symptoms: Paraplegia, infe- 
rior; vesical paralysis. Physical examination: Complete loss of mo- 
tility and sensation in both lower extremities, which are flaccid, loss 
of reflexes, bed sores. No spinal pains nor pains in affected ex- 
tremities. Later, fever, abundant mucous rales in chest. 

Autopsy: Tuberculosis of lungs, epiglottis, cervical lymph nodes 
and small intestie. In upper lumbar region of cord a hard, greenish 
central tumor surrounded by softened substance. 

Microscopical examination: Cysticercus cysts of brain. Cord; 
Tubercle 14 mm. in diameter 8 cm. from the beginning of filum 
terminale, caseous, surrounded by ring of softened tissue. Anterior 
roots at level of tubercle show atrophy. Above tubercle, interstitial 
myelitis. Below tubercle, diffuse meningo-myelitis, interstitial mye- 
litis, secondary descending sclerosis. 

Lionville. 

Nouveaux exemples de lesions tuberculeuses dans la moelle epi- 
niere, Arch, gen de med. I, 1875, 92. 

Male, aged twenty-six years. Tuberculous cachexia, general- 
ized tuberculosis) and symptoms of meningo-encephalitis and men- 
ingo-myelitis. Paraplegia and sacral bed sores. 

Autopsy: Pulmonary tuberculosis. Tuberculous meningitis, 
cord, meninges in the cervico-dorsal region show miliary tubercles ; 
tubercle replacing almost entire diameter of lower cervical region'. 

Herter, Christian A. 

"A Contribution to the Pathology of Solitary Tubercle of the 
Spinal Cord." Journal of Nervous and Mental Diseases, XVII, 
1890, 631. 

Case 1. Male, aged twenty-eight years. Has had pulmonary 
tuberculsis and tuberculous epididymitis for a year. Now complains 
of spasmodic pain in lower extremities, loss of power and then pa- 
ralysis, especially of the left leg, and hyperalgesia of both legs. 



192 W. THALHIMER AND G. B. HASSIX 

Physical examination: Showed apical tuberculosis, very active 
knee jerks, no ankle clonus. Course six weeks, with almost com- 
plete paralysis of left leg. 

Autopsy: Showed generalized tuberculosis, three massive tu- 
bercles in the brain and a solitary tubercle of the cord at the level of 
the seventh and eighth dorsal vertebrae, occupying almost entire 
left half of the cord. 

Case 2. Female, aged thirty-five years. Weakness and loss of 
power of both lower extremities, twenty days later complete paraly- 
ses and almost complete of left leg, headache, retention of urine. 

Physical examination: Bilateral loss of knee jerks, areas of di- 
minished sensation of lower extremities, bilateral diminution of 
hearing, delirium, rigidity of neck, right internal strabismus with 
dilatation of pupils and loss of light reflex. Course, one month. 

Autopsy: Miliary tuberculosis of lungs, spleen, kidney, uterus 
and tubes, ependymitis. Spinal cord showed at the level of the 
third vertebra a spheroidal mass with a cheesy center. The entire 
size is Y% inch in diameter. Microscopical examination showed a 
conglomerate tubercle with tubercle bacilli present. 

Scarpatetti, J. 

Befund von Compression una 1 Tuberkcl im Ri'tckenmarke, Jahrb. 
fur Psych., Vol. 15. 

Male aged fifty years. 

Symptoms: Pains in legs, deafness, paralysis of both lower ex- 
tremities, motor aphasia with slow onset, constipation. 

Physical examination: Pupils equal, left does not react to light, 
diminished hearing in right ear, right adhesive pleuritis, vertebral 
canal sensitive in lumbar and lower dorsal region. Lower extremi- 
ties — right shows complete loss of power, left almost complete loss 
of power. Left knee jerk absent, right knee jerk normal, ankle 
jerks inconstant, no ankle clonus. Temperature sensation equal on 
both sides, singultus, incoherent speech. 

Autopsy: Tuberculous meningitis. Body of the eighth dorsal 
vertebra contains an abscess and there is a peridural abscess at this 
level. Tuberculous pleuritis. 

Microscopical examination shows complete transverse degenera- 
tion of cord at the level of the eighth to ninth dorsal vertebrae with 
slight thickening of meninges. At the level of the second to third 
lumbar vertebrae there is a tubercle in the left anterior horn made 
up of caseous material with caseation of the central canal at this 
level. 

Krauss and McGuire. 

The Journal of the American Medical Association Oct.-Dec, 
1909, Vol. 53, p. 191 1. 

Male, thirty-six years old. Weakness and pain in chest; night 
sweats ; left pulmonary tuberculosis ; bilateral nodular epididymitis ; 
exaggerated leg reflexes; loss of bladder control, spastic paralysis 
of both legs ; loss of sensation below intermammiliary line. Lam- 



SOLITARY TUBERCLE OF THE SPINAL CORD 193 

ineetomy of upper dorsal spine: Tumor 1^2x2 cm. shelled out of 
cord about level of fourth vertebra ; tumor firm. Microscopical ex- 
amination shows giant cells and a few tubercle bacilli. 
Diagnosis: Tuberculoma of cord. 

Peter Bassoe. 

Archives of Internal Medicine, April, 1918, Vol. XXI, pp. 519- 

530. 

Male, aged thirty-five years. Girdle sensation and pain; numb- 
ness first of right, then left foot, gradually extending upwards 
Finally, spastic paralysis of both lower extremities ; exaggerated 
reflexes; almost complete anesthesia below level of eleventh inter- 
costal nerve area. 

General physical examination: Negative. Loss of bladder con- 
trol. 

Lumbar puncture: Clear fluid, cell count of three; globulin, 
positive Wassermann reaction negative. 

Autopsy: Generalized tuberculosis; conglomerate tubercle at 
spinal cord level of seventh thoracic vertebra. 



JUVENILE PARESIS ASSOCIATED WITH HYPOPITUI- 
TARISM AND SYMPATHICOTONIC TREND 
Report of a Case* 

By Theophile Raphael, M.D., and Sherman Gregg, M.D. 

KALAMAZOO, MICHIGAN 

The association of juvenile paresis, hypophyseal dysfunction and 
sympathicotonic trend, is sufficiently striking to warrant report, par- 
ticularly in the light of the added significance lately accorded the 
association of lues and pituitary disorder by Weisenburg, Patten, 
and Ahlfeldt (i) who report a series of five cases of frank pituitary 
imbalance — essentially hypofunctional — in all of which organic 
syphilis was definitely present and, in two, congenitally so. The 
added incidence of well marked sympathicotonic trend is not only of 
interest from a purely endocrino-autonomic viewpoint but, also, 
affords opportunity for speculation as to whether this relationship 
with neurosyphilis may not represent more than mere coincidence 
as in addition to the fact that various portions of the autonomic 
system are definitely known to be affected in lues, the view has 
recently been advanced by certain workers, notably Maloney (2) and 
Eppinger and Hess, (2) that vegetative disturbance may, conceivably, 
be regarded as largely responsible for the pains and crises, socalled, 
of tabes dorsalis. 

REPORT OF CASE 

R. B. (18532) white, male, aged eighteen, admitted to Kalamazoo 
State Hospital March 12, 1921. 

Anamnesis 

Family History. — The paternal grandfather died at the Kalama- 
zoo State Hospital April 6, 1912, aged eighty-five, diagnosed psycho- 
sis with cerebral arteriosclerosis. A half-brother (paternal) died 
during early adult life of what is described as a wasting disease of a 
degenerative nature, preceded by excessive alcoholism. The father 
is living at sixty and is reported as having been peculiar for many 
years. At present he manifests ideas of personal exaltation, and is 
definitely dogmatic and pedantic. There is also indication of irrele- 
vancy and circumstantiality in the stream of thought and possible 
paranoid trend. He has twice married and was divorced by both 

* Presented before the Kalamazoo Academy of Medicine, May 10, 1921. 
(From the Kalamazoo State Hospital, Kalamazoo, Michigan.) 

194 



JUVENILE PARESIS 



195 



wives apparently because of his trying disposition. Venereal infec- 
tion is denied but the blood Wassermann is four plus. Lumbar 
puncture was not obtainable and the neurological examination was 
apparently negative. The mother is living at fifty. She shows 
marked hyperthymic reaction, and complains of being nervous and 
of having suffered a nervous breakdown seven years ago. There is 
history of a still birth a year prior to the birth of the patient. The 
Wassermann on the blood is two plus. Examination of the spinal 
fluid was negative and there is no indication of neurological devi- 
ation. 

Personal History. — The mother was weak physi- 
cally during gestation having suffered an attack of 
pneumonia during this period. Labor was prolonged 
but without instrumentation. The patient weighed 
seven pounds at birth and the mother reports him as 
having been a fat baby, commencing to walk and talk 
at about fourteen months. There is history of 
chicken pox, measles, whooping cough, and several 
attacks of socalled croup during his early life and, 
since the age of seven, vision has been progressively 
defective and the body temperature noted as very 
unstable. Segmental adiposis was noted from early 
childhood. As a child the patient was bright, good 
natured and sociable, entering school at five and 
having advanced to the ninth grade by fourteen. He 
is reported to have been successful in his school 
work until about this time when the onset of a 
gradual but progressive change in his disposition 
was noted. He was soon remarked to have become 
very nervous, seclusive, generally undependable. re- 
sentful of discipline and stubborn, and to have lost 
all interest in school work. In December, 1917, the 
patient suffered what is described as a severe attack 
of influenza, following which there was remarked 
definite accentuation of the segmental adiposis and 
increased nervousness. Treatment at this time, pre- 
sumably opotherapeutic, resulted in a substantial 
loss of body weight, about thirty pounds. From this 
point on, however, there was observed rapidly progressive mental 
deterioration marked by destructiveness and frequent crying spells, 
excitement attacks and increased restlessness, irritability and con- 
fusion. A certain vasomotor imbalance, as shown by frequent and 
marked flushing was also noted. The patient became continuously 
worse and was finally committed to the Kalamazoo State Hospital, 
March 12. 1921, following an especially severe excitement attack in 
which meml)ers of the family were threatened with violence. 

Erotic libido and sex experience are strenuously denied, as is borne 
out also by the mother's statement, and there is no evidence of alco- 
holism or drug usage nor history of convulsions, snuffles or 
enuresis. 



196 T. RAPHAEL AND S. GREGG 

Examination. — Physical examination shows the height to be five 
feet five inches and weight 146 pounds. The body is very well nour- 
ished and definitely of the typus femininus with genu valgum, 
segmental adiposis (neck, cheeks, hips, abdomen, and breasts) and 
small hands with tapering fingers. The voice is somewhat high 
pitched and childlike. The lips are thick, the ears flaring, but not 
abnormally large, the palate typically of the Gothic type, and the 
teeth somewhat crowded, particularly upon the upper jaw, but show- 
ing no gross structural deviation save for impaction of the third 
molars. The skin is dry, warm and thin but of rather doughy 
consistency and shows moderately profuse acneiform eruption over 
the back and shoulders. There is definite hypotrichosis and the hair 
is of delicate texture and typically feminine in distribution, with low 
forehead hairline. The lungs and heart are negative. The blood 
pressure is no systolic and 80 diastolic and the pulse range is 80-90. 
Audition shows no disturbance save for slight diminution in air con- 
duction on the right. Vision shows marked defect being 20/70 on the 
right and 18/200 on the left with marked contraction of the visual 
fields. Examination of the fundi reveals well marked bilateral optic 
atrophy, particularly on the left. The testes are definitely hypoplastic 
and the penis small, with markedly redundant prepuce. 

Neurological examination shows fine tremor of the extended 
fingers and tongue, which deviates very slightly to the left, and slight, 
irregular twitching of the lips on speech. The pupils are irregular, 
unequal (L > R), eccentric and react very poorly to accommodation 
and not at all to direct or consensual light. The deep and superficial 
reflex responses are all definitely hyperkinetic (particularly the 
corneoconjunctival and pharyngeal responses) but otherwise show 
no deviation. There is no evidence of sensory disturbance or inco- 
ordination nor indication of clonus, Babinski, or Romberg. Speech 
is -defective showing bradylalia with definite slurring and elision, 
and handwriting is characteristically stew, awkwardly executed and 
marked by frequent elisions and mistakes in spelling. 

Mental examination shows the patient to be euphoric, mildly ex- 
pansive, slightly elated and restless, distractible, confabulative, 
childish, and somewhat confused with definite evidence of general 
deterioration in all psychic processes, particularly in the ideational 
and mnemonic fields as shown especially by defective orientation, 
poor judgment, shallow thought, and uncertainty of memory, par- 
ticularly for recent events. Psychometric examination (Stanford 
revision of the Binet-Simon test) shows a mental age of 8 % 2 years 
with an intelligence quotient of 51. 

Rontgenological examination (Dr. A. W. Crane and Dr. J. B. 
Jackson) shows undersized sella turcica but no evidence of internal 
hydrocephalus or increased intracranial pressure. The hands show 
tufting of the distal phalanges but no essential epiphyseal change 
and there is no evidence of persistent thymus. 

Laboratory examination (Dr. F. C. Potter) shows a four plus 
Wassermann reaction on the blood. Examination of the spinal fluid 



JUVENILE PARESIS 197 

shows a two plus Wassermann reaction ; Nonne-Apelt reaction phase 
i and 2. four plus ; pandy four plus ; moderate reduction of Fehling's 
solution; 46 lymphocytes; colloidal gold 5533333210; and mastic 
5554443210. The urine is negative save for slight volume increase, 
1875 cc - P ms l°ss at stools. Examination of the blood shows: 
hemoglobin jy per cent.; erythrocytes 4,525.000: color index 0.85; 
leucocytes 14,000; polynuclear neutrophiles 83 per cent.; small 
lymphocytes 8 ; transitionals 9 ; eosinophiles o. 

Endocrine and vegetative examination shows marked increase 
of sugar tolerance (Janney and Isaacson) (3) as follows: 

Fasting level. 0.101 

One-half hour after ingestion of glucose 0.125 

One hour after ingestion of glucose 0.109 

Two hours after ingestion of glucose 0.125 

Three hours after ingestion of glucose 0.102 

The basal metabolism (Jones) (4) was slightly decreased (-10.9 
per cent.). The hypodermic injection of one ing of epinephrin 
hydrochloride, was followed by very marked tremor, pulse increase 
of sixty-five beats per minute and heavy glycosuria. The oculo- 
cardiac reflex showed inverted response with an acceleration of 
eight. There was noted no increased sensitivity to the hypodermic 
administration of pilocarpine (one eighteenth gr.), eserin (one- 
fourth mg.) or atropin (Moo gr.)- Temperature (mouth) shows 
a range of 97.6°-98.4°. The Sergent adrenal white line was noted 
as well as moderate dermagraphia. 

Discussion 

On analysis, the existence of general paresis of the juvenile type 
is readily established from the rather typical onset, characteristic 
mental deterioration with linguolabial tremor, dysarthria, hand- 
writing defect, pupillary disturbance, optic atrophy, reflex hyper- 
kinesia, and typical blood and fluid findings with evidence of con- 
genital somatization and specific parental infection. 

Pituitary hypof unction may be validly assumed on the basis of 
the general physical appearance, e.g., typus femininus with seg- 
mental adiposis, small hands, tapering digits, gonadal hypoplasia and 
hypotrichosis with typically feminine distribution and fine hair 
texture, childish voice, undersized sella turcica and markedly in- 
creased sugar tolerance with slightly reduced basal metabolism, 
erythrocyte count and hemoglobin content, and association with 
somewhat low vascular tension, slight polyuric tendency and low 
grade hypothermia. 

It may be noted in addition that low forehead hairline, crowded 
dentition, thin doughy skin, and Sergent line, as reported by Weisen- 
bttrg and his associates in their cases of associated lues and pituitary 



iq8 T. RAPHAEL AND S. GREGG 

dysfunction were also noted in this case, as well as indication of 
terminal digital tufting. There was, however, no indication of 
enuresis as determined in three of their cases, nor eosinophilia, 
lymphocytosis, or disproportionate torsoleg ratio as noted in all five. 

The significance of the Sergent white line, present in this case, is 
of interest although somewhat obscure. From recent work by Kay 
and Brock (5) this sign appears to bear no relation to adrenal tone 
as formerly supposed. Its observance by Weisenburg, Patten and 
Ahlfeldt in their cases of combined lues and hypophyseal disturb- 
ance, and in our case, associated with well marked dermographia 
and sympathicotonic trend, affords indication that it might conceiv- 
ably be regarded as a manifestation of general vasomotor imbalance, 
dependant possibly upon autonomic dysfunction, basic in turn to 
either, or both, primary disturbing factors, syphilitic infection and 
hypopituitary trend. 

The existence of sympathicotonic trend may be inferred, posi- 
tively, from the very definitely exaggerated sensitivity to epinephrin, 
inverted oculocardiac response, rapid pulse, warm dry skin, 
increased corneoconjunctival and pharyngeal responses, good nutri- 
tion, bright superficially placed eyes and general hyperthymic trend 
and, negatively^ by lack of sensitivity to pilocarpine, eserin or atropin 
and absence of eosinophilia. 

This association of sympathicotonic trend and pituitary hypo- 
function is somewhat unusual, particularly as it has been commonly 
reputed, as indicated recently by Langdon Brown (6), that the 
pituitary, with the adrenals and thyroid, comprises what might be 
termed a sympathicotropic triad ; all three of these glandular systems 
being excited to greater activity by the sympathetic division of the 
autonomic nervous system and, in turn, stimulating this division to 
increased function. From this point of view, if such were the case, 
a diminished spmathetic tone or sympathicatonic trend, as it were, 
might have been anticipated in this instance rather than increased 
sympathetic tone, as actually determined. However, it is possible, 
that the presence of sympathetic hyperactivity, in this case, may be 
an indication of compensation-attempt on the part of the two remain- 
ing members of the triad (adrenals and thyroid) and the sym- 
pathetic, although such presumption is admittedly speculative. 



JUVENILE PARESIS 199 

Summary 

Report is made of a case evidencing, in significant relief, the 
association of a luetic process (juvenile paresis) with deficient 
hypophyseal functioning and sympathicotonic trend, affording in- 
dication of the importance of systematic vegetative and endocrine 
analysis in acquired and congenital syphilis, particularly where 
associated with nervous system involvement. 

Grateful acknowledgment is made to Dr. Herman Ostrander, 
medical superintedent, for permission to study and report this case. 

BIBLIOGRAPHY 

1. Weisenburg, T. H., Patten, C. A., and Ahlfeldt, F. : Five Cases of Pitu- 

itary Disease. Archives Neurol, and Psychiat., 5 (May), 1921, 618. 

2. Quoted by Jelliffe, S. E., and White, W. A. : Diseases of the Nervous Sys- 

tem, Philadelphia, 1919, 739 and 148. 

3. Janney, N. W., and Isaacson. V. I. : A Blood Sugar Tolerance Test. /. 

A. M. A., 70, 1 131 (Apr. 20). 1918. 

4. Jones, H. M.: A Simple Device for Measuring Rate of Metabolism. Arch. 

Int. Med., 27-48 (Jan.), 1921. 

5. Kay, W. E.. and Brock. S.: The White Adrenal Line (Sergent) ; its Clin- 

ical Significance. Am. Jr. Med. Sci., 161-555 (Apr.). 

6. Brown, L. : The Sympathetic Nervous System in Disease, London, 1920. 

23. 



PROGRESSIVE CEREBRAL HEMIPLEGIA: ITS PATHO- 
GENESIS AND DIFFERENTIAL DIAGNOSIS* 
By Alfred Gordon, M.D. 

PHILADELPHIA 

Under the term progressive cerebral hemiplegia is understood a 
condition in which a unilateral paralysis of cerebral type is estab- 
lished slowly and progressively but in sections, commencing either 
in the upper or in the lower extremity or else in the face. The 
pathological material in such cases has been found to present a great 
variety. Edema of a whole hemisphere, large areas of softening, 
obliteration (partial or complete) of the internal carotids, thrombosis 
of the Sylvian arteries, multiple foci of softening through arteritis 
of small bloodvessels in the cortex or centrally located; finally 
tumor of the brain — these are the anatomical conditions which have 
been observed by various authors in the form of hemiplegia under 
consideration. Before discussing further the pathogenesis of the 
condition the following cases are presented for consideration : 

Case I. — Man aged fifty-five, with a history of a syphilitic in- 
fection at the age of thirty-five, commenced to suffer from attacks of 
vertigo several months previously. His heart was somewhat en- 
larged, the aorta presented a marked accentuation of the second 
sound; the blood pressure was 170 systolic. Urinalysis showed a 
faint trace of albumin. One morning after a more violent attack of 
vertigo than usual, he felt the left arm and hand become numb, he 
rubbed the limb with vigor to make it react ; on the following day 
the arm became paretic. Gradually the paralysis became more and 
more pronounced. On the tenth day the left lower limb became 
similarly involved and finally the left side of the face became 
deviated to the right. The speech was at no time affected except 
toward the end, when the patient's mentality became greatly weak- 
ened. In addition to the hemiplegia there was also a total hemi- 
analgesia in the left arm and leg but only a hypalgesia in the lower 
half of the face on the same side. The reflexes were all typical of a 
cerebral attack. The eyes were normal, with the exception of a 
slight limitation of their movement toward the left. The tongue was 
deviated to the left side. There was no difficulty of deglutition. The 
sphincters were normal. The patient's condition gradually grew 
worse, the paralytic state became deeper, the sphincters ceased to 
functionate, the patient became mentally dull and gradually a coma- 
tose state made its appearance. Death occurred on the twenty-eighth 
day. 

* Read before the meeting of the American Neurological Association, 
May, 1 92 1. 

200 



PROGRESSIVE CEREBRAL HEMIPLEGIA 201 

At autopsy considerable edema was present over the Rolandic 
area in the right hemisphere. Both ascending convolutions were 
pale and on palpation a softness of the tissue was felt. The soft 
consistency was particularly marked in the middle portion of the 
precentral convolution, but less marked in its upper third ; the lower 
third presented the same consistency as the surrounding tissue. 
Transverse cuts revealed that the entire cortical layer was corre- 
spondingly softened and contrasted sharply with the normal tissue 
but the softening did not penetrate deeper and left the white sub- 
stance untouched, except over a very thin layer immediately close 
to the gray matter. The basal ganglia remained intact. The most 
interesting finding is the condition of the right middle cerebral 
artery ; at its origin where it leaves the internal carotid, it was found 
• to be hard on palpation ; a section of it revealed an almost complete 
obliteration of the lumen. Dilatation of the basilar artery was 
another interesting feature. A microscopical study of these arteries 
showed distinct evidence of endarteritis, which was probably of 
luetic origin, but on the other hand the small arteries distributed 
over the Rolandic area did not show any material changes. A 
histological study of the nerve tracts showed distinct degenerative 
changes with the Marchi method but very slight with Weigert's stain. 
Special emphasis is laid on the fact that the most pronounced 
softening of cortical tissue was in that portion of the Rolandic area 
which corresponds to the center of the arm. and it is to be recalled 
that the paralytic condition commenced in the arm. 

Case II. — Man aged sixty-three, an inveterate alcoholic, had had 
attacks of vertigo with severe headache for a number of years. 
After one of these attacks in which the vertigo was unusually severe 
he became unconscious. Fifteen minutes later he commenced the re- 
gain consciousness and it was noticed that the left leg was paretic. 
The reflexes showed an involvement of the motor pathway. Sensa- 
tions to all forms were greatly diminished. The paralysis of the leg 
became more and more pronounced. Ten days later there was ob- 
served a gradual diminution of power in the left arm with an accom- 
panying flaccidity. Shortly afterwards a slight deviation of the face 
to the right was noticed. The patient was under observation until he 
expired, thirty days later. During that period he presented a typical 
left motor hemiplegia with a diminution of sensibility to all forms on 
the same side. Gradually the sphincters became involvement. The 
mentality remained clear until the end. The patient's blood pressure 
oscillated from 200 to 160 systolic. The left cardiac ventricle was 
dilated. 

At autopsy the findings were as follows : Both hemispheres were 
edematous with predominance over the right sensorimotor area. At 
this level a pronounced vascularization could be seen. The lower 
portion of this area was somewhat softer than the neighboring tissue. 
Inspection and palpation revealed a more or less solid consistency 
of the arteries over the convexity and at the base of the brain. Only 
in one place a nodular condition was detected, it was at the level of 



202 ALFRED GORDON 

origin of the right Sylvian artery. A section of the latter showed an 
almost complete obliteration of the lumen. Further examination 
showed that the ascending frontal convolution was more softened 
than the ascending parietal, a fact which probably has some bearing 
upon the difference of the degree of involvement of objective sensi- 
bility and motor disorder during the patient's life. The softening 
was only peripheral but it gained also in depth. A gross section 
showed an edematous state in the right hemisphere between the 
periphery and the basal ganglia. However a certain portion of the 
internal capsule and of the adjacent lenticula was found softened, 
but the knee and the upper part of the capsule, as well as the thala- 
mus were intact. Histological examination showed marked athero- 
matous changes in many of the cerebral arteries, which were par- 
ticularly evident in the internal layer of the vessel wall. It was 
unusually pronounced in the Sylvian artery of the level of the 
above mentioned obliteration. The cortical cells showed marked 
deformities with a certain degree of chromatolysis. As to the nerve 
fibers some degenerative changes were traced only with the Marchi 
methods. 

Case III. — Man aged sixty-five, during the last ten years of his 
life severe attacks of mild subjective sensory disturbances in his 
left hand and foot. They consisted of tingling with numbness 
followed by weakness in the left arm and leg. The first attack 
lasted a few hours, but each subsequent attack was longer in duration 
so that the duration of the last one was a whole week. While he 
always recovered from each seizure, the fifth which was the last 
left his left arm somewhat weak. Nevertheless this weakness did 
not interfere with his regular occupation which was clerical. About 
fifteen days later his left arm became totally paralyzed and this 
occurred after an attack of vertigo without loss of consciousness. 
Five days later the left leg became paralyzed and at the same time a 
deviation of the face toward the right was noticed. The paralysis 
became gradually deeper and deeper and presented the typical 
symptoms of cerebral motor hemiplegia. Sensations were but 
slightly involved. There were no eye manifestations and the sphinc- 
ters were intact. The patient presented a high blood pressure 220 
systolic. The heart was dilated and the second aortic sound was 
loud and musical. Arteriosclerosis was pronounced. On the twenti- 
eth day the patient's condition became suddenly worse, a comatose 
state set in and he expired. 

Autopsy revealed a marked edema in the right hemisphere. The 
pia was thick and infiltrated so that when after a puncture the 
edematous fluid escaped, it collapsed on the surface of the brain. 
There was distinct softening on the Rolandic area and particularly 
in its median portion, more in the precentral than in the postcentral 
convolution. The softening encroached somewhat on the prefrontal 
lobe in the middle portion. The arteries of the convexity of the 
entire cerebrum as well as of the base appeared thick and on palpa- 
tion they felt hard. A specially hard area was found in the Sylvian 



PROGRESSIVE CEREBRAL HEMIPLEGIA 203 

artery at the level of its origin. A cut of that area showed an 
almost complete obliteration of its lumen. A number of cuts were 
made over other arteries as well as those of the base. Thickened 
walls were in evidence in the majority but no obstruction of the 
lumen was seen. Transverse cuts of the brain revealed that the 
softening penetrated through the entire thickness of the cortex. 
An area of softening was found in the right internal capsule back 
of the knee. The thalamus opticus was intact but a small area of the 
lenticula adjacent to the capsule was also softened. Microscopical 
examination showed besides cellular changes in the cortex also 
degenerative changes in the motor pathway more with the Marchi 
than with Weigert's method of staining. 

Case TV. — Man aged thirty-eight, complained of severe head- 
ache, vertigo and had frequent vomiting spells. The tendon reflexes 
were increased in the lower extremities, but no other abnormal 
reflex was present. The eyegrounds were negative for a long time. 
The condition remained unaltered during a period of four months. 
At that time the patient observed a gradually oncoming weakness in 
the right arm with a mild difficulty of speech. Examination revealed 
also a sensory disorder in the affected arm. consisting of a pro- 
nounced hypesthesia to all forms of sensations ; the patient com- 
plained of a numbness in the fingers and of inability to appreciate 
objects ; astereognosis was present. The paretic condition grew 
deeper and deeper when on the sixth day the right leg became paretic. 
Gradually a complete paralysis of the leg developed. The face was 
but slightly involved. The speech became more and more typical of 
motor aphasia. Soon the patient's eyes commenced to show symp- 
toms. Diplopia occurred frequently. The eyegrounds showed a 
haziness of the media, optic neuritis rapidly developed on both sides. 
The headache became more severe, vomiting more frequent. Con- 
vulsive seizures appeared on the right side. A comatose state 
gradually set in and the patient expired in one of the convulsive 
attacks. At autopsy a gliomatous neoplasm was found in the left 
hemisphere involving the ascending parietal convolution and partly 
the ascending frontal close to the Rolandic fissure affecting theif 
median portion. 

Case V. — Man, sixty-four years of age, after a prolonged period of 
vertigo there developed five months ago a sudden paresis, with a 
sensation of numbness in the right leg. At the end of seven days 
he regained considerable power. Nevertheless a certain awkward- 
ness of gait remained. Two months later a similar condition 
appeared in the right arm and leg. The face was also seen to deviate 
towards the left. The paresis became gradually more and more 
pronounced so that at the end of the fifth month the patient presented 
a complete right hemiplegia. Presently there was not only paralysis 
on the right side but also motor aphasia. The sensations were 
diminished on the right side. All the reflexes were typical of cases 
with a cerebral damage. The patient gradually grew weaker. 
Diarrhea made its appearance. Coma and death followed. At 



204 ALFRED GORDON 

autopsy was found a softening of the entire posterior limb and 
posterior portion of the anterior limb also of the knee of the left 
internal capsule. The large arteries of the convexity and base 
of the brain were found hard on palpation. 

The clinical aspect in the five cases presents common character- 
istics, viz., the paralysis developed slowly and gradually at first as a 
mere weakness in one limb, but this imperceptibly grows more and 
more profound until a complete and total hemiplegia is fully estab- 
lished. The paralysis may commence in one or another extremity. 
In three cases the onset was in the arm, in two in the leg. The face 
as a rule becomes involved simultaneously with the arm. Sensations 
were invariably involved. In the first case there was a total 
analgesia on the affected side, in the second case — great diminution, 
in the third and fifth hypesthesia to all forms of sensations and in 
Case IV almost complete abolition of the superficial sensations and 
astereognosis. 

Special emphasis deserves the onset of the condition : In all the 
cases except Case II, there was no suddenness which is so frequently 
the case in apoplexy ; a mild paresthesia with a weakness in one limb 
is most characteristic of the invasion of progressive hemiplegia. The 
prodromal period in the five cases presented a state of vertigo and 
the onset of the unilateral paresis was invariably preceded by an 
unusually severe vertiginous state. 

The anatomical findings require special consideration. In the 
first three cases we see a marked edematous state of the cortex with 
deep softening. Total obstruction of the main artery supplying 
the cortex was in evidence. The area of softening and the apparently 
anemic appearance of it is in sharp contrast with the neighboring 
tissue which remains firm. Edema and softening penetrate the brain 
through the entire thickness of the cortex and involve partly the 
white substance. The edema uniformly found in each of the three 
cases over a limited region naturally suggested a vascular obstruction. 
Indeed in each of these cases obliteration was found in the Sylvian 
artery although at a different level, but near its origin. The obstruc- 
tion was complete. In Case IV we deal with a gliomatous tumor 
which for a long time (many months) did not show marked symp- 
toms of increased intercranial pressure, as evidenced by the absence 
of focal symptoms and eye manifestations. No edema of the 
surrounding tissue was observed. In Case V there was a softened 
internal capsule and again no edema. Except Case IV with tumor, 
in all the other four cases there was distinct and pronounced 
degenerative changes in the blood vessels. 



PROGRESSIVE CEREBRAL HEMIPLEGIA 203 

In view of these anatomical data let us consider the pathogenesis 
of progressive cerebral hemiplegia. 

In Cases I, II, III, and V we find during the patient's life 
evidences of endarteritis, viz., frequent attacks of vertigo with peri- 
pheral arteriosclerosis. Arteritis, symptomatic of localized edema, 
is a well known fact in pathology. The first consequence of interfer- 
ence with arterial circulation in complete or even partial closure of 
the lumen of an artery is a more or less pronounced stasis in the 
neighboring veins and a passive dilatation of the latter. The passive 
dilatation is facilitated by a vasomotor paralysis which is usually 
present in such cases. In the cases under discussion by virtue of 
arterial alteration partial obliteration was being produced very 
slowly and over a long period. The edematous state of the nervous 
tissue was consequently equally slow and according to the intensity 
and the seat of the. edema corresponding symptoms made their 
appearance. When an obliteration becomes complete in an artery 
which irrigates a given region, edema is pronounced and total 
suppression of function in the affected area will be the result. In the 
case of tumor the mechanism of progressive hemiplegia finds its 
explanation first in the consistency of the mass and secondly in the 
gradual encroachment of the latter on the various centers of the 
Rolandic area. The softness of the neoplasm prevented a stormy 
onset with its usual abrupt or sudden development of paralysis, with 
or without loss of consciousness; it produced slight but progressive 
pressure on the important sensorimotor area with the result of a 
gradual and mild interference of function dependent on the involved 
portion of the brain. A paretic condition was the first and a complete 
extensive paralysis was the final step. 

The five cases described here permit to draw this conclusion that 
progressive cerebral hemiplegia may be encountered in endoarteritis 
from arteriosclerosis, in obliteration of a large artery such as the 
middle cerebral and in tumors especially of gliomatous type. But 
in Case I, in addition to the arteriosclerosis incidental of the patient's 
age there was also a history of syphilis. The sclerosis of the blood- 
vessels may be considered in a causal relationship with lues. That 
syphilitic infection at any of its periods may produce paretic condi- 
tions in one limb or partial paralysis is a well known fact. It may 
also cause a paralysis in a portion of the body on one side and later 
on produce identical conditions in the remaining portions of the 
same side. I have in my possession facts of this order of a clinical 
order. I observed in the tertiary period of syphilis, as well as in 



206 ALFRED GORDON 

tabes, progressive cerebral hemiplegia precisely with the same char- 
acteristics as those seen in the cases described above. In fact in all 
instances of partial paralysis lues should be suspected and if the 
laboratory tests are all confirmatory, they should be managed 
accordingly. The recognition of this possibility is preeminently 
important as cerebral ischemia may be prevented if the preobliterat- 
ing phase of arteritis can be handled successfully. Syphilis of the 
nervous system as a rule presents no difficulty of diagnosis. The 
accompanying changes in the reflexes, in the reactions, dimensions 
and form of the pupils, in the function of the ocular muscles, in the 
function of the sphincters — are all adequate enough in presuming a 
luetic state. Particular reliance however should be placed on the 
Wassermann reaction of the blood and spinal fluid, on the cytological 
state of the latter, namely lymphocytosis. 

Partial and incomplete hemiplegia occurring abruptly without 
loss of consciousness, mostly bilaterally and commencing frequently 
in the upper extremities, soon showing improvement (but not re- 
covery) and remaining flaccid, if ever reaching the state of con- 
tracture, is observed in aged individuals and it is due to a successive 
formation of lacunar foci in the cerebrum. This condition was first 
described by Marie, Ferrand, and Leri. The successive appearance 
of the symptoms may give the impression of a progressive hemi- 
plegia as described above, but the occurrence in old age together with 
other evidences of pathological senility, such as speech disturbance 
and psychic changes, namely flaccidity, also the tendency to amelio- 
ration, the cilaterality of the motor disorder, — all these features will 
aid in building up the correct pathogenesis of the condition. 

Progressive hemiplegia may occur in cases of aneurisms of the 
basilar artery. Such a case is reported by de Massary and Carton 
{Bulletin de la Societe Anatomique, Juillet, 1901). The patient, 
aged forty-three, had at first a slight hemiparesis on the left side, face 
including. There was some dysarthria. The latter rapidly improved. 
Soon the paralytic condition commenced to increase and gradually 
became complete and profound. The speech disorder reappeared. A 
comatose state set in and the patient expired. At autopsy an 
aneurysm was found on the right side of the basilar trunk which was 
compressing the upper and internal third of the right side of the pons. 
A section through the latter showed that the aneurismal sac pro- 
duced not only pressure but also and more so a disorder through 
the disturbed vascular supply causing a focus of softening in the 
middle cerebellar peduncle and in the right pyramid. The ad vitam 



PROGRESSIVE CEREBRAL HEMIPLEGIA 207 

diagnosis was very difficult in view of absence of cranial nerve 
involvement : The oculomotor, facial and trigeminal nerves were all 
intact. 

Progressive hemiplegia has been observed in cases of uremia and 
at autopsy an edematous state of the cortex with a localized pre- 
dominance over the motor area was found. Whether the edema is 
due to the accompanying endarteritis frequently found in such cases 
or to the toxic action of the pathological urine, or else to both 
elements, one cannot be certain. At all events one must bear in 
mind the possibility of occurrence of a progressive paralysis in 
uremic states. However, the distinguishing features will be found, 
in brief, alternating phases of aggravation and retrogression of the 
paralytic phenomena. 

A similar tendency to retrogression in paralysis is observed in 
diabetes in the course of which progressive hemiplegia is sometimes 
observed. It is very probably due to a vascular lesion produced 
by intoxication of diabetes. Analogous condition and pathogenesis 
have been observed in intoxications from other sources, such as 
saturnism, carbon monoxide, alcoholism. 

Tuberculous meningitis is another affection in which a slow 
and progressive paralysis of the limbs on one side of the body is 
sometimes observed. Chantemesse was the first to call attention to 
it (These de Paris, 1884). Here again a vascular disorder caused 
by the tuberculous process might be incriminated. It must be 
pointed out that here like in uremia the intensity of paralysis is 
liable to alternate in the course of the disease, but invariably it termi- 
nates by a complete and permanent hemiplegia. 

In 1846 (Medical Times, London) Fletcher described a symptom- 
group under the name of ingravescent apoplexy which was subse- 
quently studied among many other observers by Broadbent (Medico- 
Chirurg. Transactions, V. L, IX, 1876), Abercrombie, Thomas 
Watson, Mosse (Gas. hebdom. de Montpellier, 1889) an d Peuch 
(Progres Medical, 1889). Pathologically the affection is character- 
ized by a hemorrhagic focus situated between the striate body and 
the external capsule. The clinical picture is as follows : In the be- 
ginning there is usually a sudden and severe headache ; the patient 
is pale, the body becomes cold, the pulse is feeble and the individual 
falls in syncope. Sometimes the initial symptom is mental confusion. 
The syncopal state is usually brief. After having regained con- 
sciousness the patient continues complaining of headache. After a 
more or less brief period the patient becomes incoherent and suddenly 



208 ALFRED GORDON 

coma sets in from which he never recovers. Paralytic symptoms 
may be or may not be present. If it does appear it usually develops 
slowly and by gradation so that eventually complete hemiplegia will 
ensue. In the latter case the resemblance to the clinical picture of 
progressive hemiplegia described above is striking. A careful analy- 
sis however will show fundamental differences between the two 
affections. In ingravescent apoplexy the paralytic symptoms may 
sometimes be entirely wanting. In cases in which they are present, 
there are always stormy manifestations characteristic of an apoplec- 
tic insult, viz., sudden loss of consciousness. Coma appears soon 
after consciousness has been regained and increases progressively. 
In progressive hemiplegia on the contrary, a comatose state appears 
as a terminal phase a long time after the hemiplegia has been 
established. Besides, the state of malaise with headache and vomit- 
ing described above as immediately preceding the syncopal state of in- 
gravescent apoplexy is entirely absent in the syndrome of progressive 
hemiplegia. The difference between the clinical pictures of one and the 
other cerebral condition finds its corroboration in the anatomical 
findings : while in ingravescent apoplexy there is always a hemor- 
rhage, in progressive hemiplegia there is an area of softening which 
may be caused by a multiplicity of lesions, such as we have seen in 
the beginning of this work, viz., endarteritis, obliteration of middle 
cerebral arteries, pressure from a tumor, aneurism of the basal 
arteries, a degenerative state of the arteries of syphilitic nature. 
In 1899 Thomas and Long (Comptes rendus hebdomadaire des 
seances de Societe de Biologie, No. 28, 1899, p. 768) report an 
anatomoclinical case resembling to some degree progressive hemi- 
plegia under discussion. It was a case of a man aged forty-seven, 
with a history of syphilis at thirty-six. Seven years before his death 
there gradually developed a paresis of the right leg which eventually 
became permanently paralyzed. There was also a complete anes- 
thesia in the leg. About a year later a paresis of the right arm made 
its appearance. Gradually spincter disturbances made their appear- 
ance and a year later the patient died, after an acute attack of 
pleurisy. At autopsy several plaques of sclerosis were found in the 
spinal cord. The condition in the opinion of the author reminds one 
of some of the lesions in spinal syphilis. Another similar case but 
without autopsy findings was described by Mills {Journal of Nervous 
and Mental Disease, 1900, 27, p. 95). In a man of fifty-two a 
gradual weakness and awkwardness developed in the right lower 
extremity. Eighteen months later an identical condition appeared 



PROGRESSIVE CEREBRAL HEMIPLEGIA 209 

in the right arm. The face was also involved in its right half. The 
paretic condition of the two limbs did not increase for a long time 
and there was no sparsticity. The condition of the reflexes pointed 
to an involvement of the motor tract. The sensations were normal 
but atrophy of the musculature was present on the right side. The 
author expresses the opinion of the case being probably an example 
of a slowly increasing degeneration of the cerebral motor neuron 
system. 

The two cases just reported present a progressive development 
of a unilateral paralysis, but the mode of onset and the course of 
the disease — the character of the paralytic symptoms, the termination 
and the absence of arterial manifestations, finally the autopsy findings 
in one of them, — all prove a fundamental difference with the syn- 
drome of progressive cerebral hemiplegia described in the present 
contribution. 



Current Literature 



II. SENSORI-MOTOR NEUROLOGY. 
6. BRAIN. 
Von Monakow, P. Uremia. [Schw. Arch. f. Neur. und Psych., 1920, 

6, No. 2. J. A. M. A.] 

Von Monakow recalls that there are no characteristic signs of the 
uremic nature of a hemiplegia or other clinical picture except the knowl- 
edge of existing kidney disease. He protests against the assumption that 
the residual nitrogen is a reliable index of kidney functioning, and also 
that edema of the brain alone is able to induce convulsions. For this, 
some toxic factor is indispensable. With mechanical retention of urine, 
cerebral focal symptoms are rare, and when they occur they are variable 
and fleeting. With chronic nephritis, uremic coma is liable to develop 
suddenly without any apparent special factors at the moment to bring it 
on. These and other data cited suggest that something beyond the mere 
retention of the elements of urine is responsible for uremic coma, some 
factor independent of the kidneys. This factor, he thinks, is the sudden 
yielding of the choroid plexus to allow passage of injurious substances. 
As long as the choroid plexus is normal, it serves as a protecting mem- 
brane to ward off toxic fluid from the brain. When it becomes abnor- 
mally permeable, the brain is flooded with the noxious elements circulat- 
lating in the blood stream. He gives photomicrograms from two cases, 
showing the pronounced fibrous and other changes in the choroid plexus 
found after death in uremic coma. 

Noica. Combined Voluntary Movements. [L'Encephale, 1920, June, 

Vol. 15, p. 390.] 

In following the development of voluntary movements at various ages 
it is found that combined voluntary movements are the first to make their 
appearance. New born infants make combined movements with the en- 
tire body and of various members which seem to have neither sense nor 
utility. The first purposeful and limited movements appear at the begin- 
ning of the fourth month when the infant grasps for the mother's breast 
with its two hands. The first separate voluntary movements of the 
lower members appears in connection with attempts to walk when the 
infant has reached the age of one year. It is only later, however, that 
limited movements of the fingers or hands in the upper members or of 
the knee, foot or other articulations in the lower members make their 
appearance. But even in adults the tendency to make associated move- 
ments persists under some conditions. The same rule holds good of the 
face: If a child or uneducated person is told to close one eye the 

210 



SENSORI-MOTOR NEUROLOGY 211 

whole side of the face is moved. The author agrees with Mueller's 
explanation of the mechanism of* these combined and separate move- 
ments. The child comes into the world with a tendency to make sym- 
metrical and identical movements and by education and exercise learns 
to single out the separate voluntary movements of the different articula- 
tions of the body. The author endeavors to answer the question on the 
basis of this mechanism why the combined voluntary movements reap- 
pear in certain cases of adult hemiplegia, but not in all. He finds the 
answer in the analysis of the movements of various patients examined 
by him. The sign of Strumpell, for example, is a combined movement 
partly modified by a predominant paralysis of the extensors of the last 
four toes with the relative conservation of the motility of the anterior 
muscles of the limb and of the long extensor of the great toe. In lesions 
of the pyramidal bundle the first movements to disappear in the lower 
membranes are the later acquired limited movements — in the case of 
Striimpell's phenomena the power of separately moving the great toe. 
Another paralytic examined by the author could not close the hand with- 
out bending the elbow, nor bend the elbow without closing the hand— 
which constituted the infantile combined voluntary movement. These 
combined movements are only observed in those patients who have pre- 
served at least a part of their power of voluntary movements. The 
author concludes that combined movements are an economy of force 
while the dissociation of these movements, i.e., their isolation by inhibit- 
ing other from setting in, represents a greater expenditure of force, a 
higher form of adaptation. The adult having a lesion of the pyramidal 
bundle destroying the powers of particular adaptations tends to have 
combined movements, therefore, rather than to dissociate them. [J.] 

Ducroquet, C. Hemiplegia in Children. [Presse Med., July 24, 1920. 

J. A. M. A.] 

Ducroquet shows in this profusely illustrated article the gait with 
hemiplegia, and advocates active movements of the knee and hip joint 
as the best means to restore functional use of the muscles. They may 
have to be preceded by passive exercises to stretch the contracted mus- 
cles. The knees, for example, can be strapped to a board as the patient 
sits with his back against a wall or the straight back of a chair. The 
equinus deformity of the foot can be corrected in young children by an 
elastic, fastening up the tip of the foot. An appliance should be worn 
at night to maintain this correction. Tenotomy may be indispensable 
in the severer cases, but much can be accomplished by pressure on the 
metatarsus as the knee is flexed. This relaxes the triceps at its attach- 
ment to the femur. Holding this corrected position with a plaster cast, 
the muscle finally relaxes permanently and two or three casts complete 
the process. Healing is complete sooner if the knee is enclosed in the 
cn^t. 



212 CURRENT LITERATURE 

Mirallie, C. Blood Pressure iv Hemiplegia. [Bull, de la Soc. Med. 

des Hop., June 25, 1920.] 

Examinations of the blood pressure on both sides in sixteen women 
and four men with hemiplegia are here reported upon, The observer 
found the maximum pressure was usually lower on the paralyzed side, 
minimal was alike. Edema when present was referred to heart or kid- 
ney mechanisms rather than to central vasomotor disturbance. 

Marie, Pierre, and Foix, Chas. Paraplegia with Contractures in 
Flexion of Cerebral Origin Due to Progressive Subependymal 
Necrosis. [Revue Neurologique, January, 1920.] 
The patient, aged seventy years, suffered from a paraplegia with the 
legs in extreme flexion, which had developed gradually. There was 
marked dementia with spasmodic laughter. The upper extremities were 
practically normal. The knee and Achilles jerks were abolished. The 
plantar reflex was extension on the right. The reflexes of spinal au- 
tomatism were present and marked. The anatomic examination showed 
a marked dilation of the ventricles on both sides but mostly upward 
and forward. The walls of the anterior horn were irregular and these 
irregularities appeared on section to be due to progressive subependymal 
necrosis with cicatrix formation. The necroses were so situated that 
they interrupted the fibers from the paracentral lobules on both sides, 
this causing the paraplegia. The mesencephalon was normal. The case 
shows that the typical paraplegia " en flexion " as described by Babinski, 
with dissociation of the tendon reflexes and the spinal automatism, may 
be due to cerebral lesions. [Camp.] 

Davidenkof, Serge. Early Contracture of Reflex Origin (Syndrome 
Hormetonique). [Revue Neurologique, January, 1920.] 

The syndrome hormetoniques is a name coined by the author from 
the two Greek words meaning "attack" and "tension. ' 

In separating the hemiplegics who develop contractures early from 
those of late development, it is generally assumed that the former are 
due to irritation of the pyramidal tract. The author believes, however, 
that they are more on the order of reflexes resembling especially the 
reflexes of defense. In view of the fact that spasmodic contractures can 
occur from irritative lesions the author creates the new word to describe 
his observations. [Camp.] 

Schott. Birth Injuries as a Cause of Infantile Epilepsy and Imbe- 
cility. [Arch. f. Gynak., CXIII, 2, 1920.] 

The chief factor in the etiology of convulsive seizures and imbecility 
in children is to be found in hereditary influences; injuries at birth play 
a very small part. An examination of over a thousand cases shows that 



SENSORI-MOTOR XEUROLOGY 213 

in only 3 per cent, of imebeciles, and just over 1 per cent, of epileptics, 
was injury at birth the chief circumstance to which the pathological 
condition could be attributed. 

Laignel-Lavastine. Aphasia and Apraxia. [Bull. med.. March 20, 

1920.] 

In the report of a clinic the author's views on aphasia and apraxia 
are detailed. He divides aphasia into two groups, according to whether 
there is difficulty of interior language, and studies spontaneous speech, 
repetition, spontaneous writing, writing from copy and from dictation- 
comprehension of written and spoken words. The Proust-Wernicke- 
Lichtheim-Dejerine test, in which the patient is shown an object and 
asked to open and close the hands as many times as there are syllables 
in the word is reacted to by failure when the aphasia is intrinsic. This 
class is divided into two groups, aphasias of Broca. where the ability 
to articulate is lost, and aphasia of Wernicke, characterized by loss of 
comprehension. Extrinsic aphasias where there is no difficulty of the 
interior language are divided into four groups, pure motor aphasias, 
pure alexia, agraphia and pure word deafness. Three apraxias are 
classified, the ideational apraxia or apraxia of conception, ideomotor 
apraxia or apraxia of transmission and motor apraxia. or apraxia of 
execution. These disturbances are analyzed by tests of simple, reflex, 
expressive, description and transitive movements. To distinguish be- 
tween apraxia and ataxia the ability of the patient to direct his thought 
toward an end is important. The ataxic patient does this hesitatingly 
and his conception of the end is correct. He can complete the action 
and improve it. The apraxic patient does not improve by repetition. 

The lesion in ideomotor apraxia is localized in right handed persons 
in the left parietal lobe, more especially in the left supramarginal gyrus. 
A lesion of the left cerebrum determines a bilateral apraxia, predomi- 
nating on the right. If the apraxia predominates or exists alone on the 
left, in a right handed person, there is also either a lesion of the corpus 
callosnm or an associated lesion of the right cerebrum. Aphasia is a 
particular case of apraxia. Ideatory apraxia corresponds to dyslogia. 
motor aphasia to anarthria and ideomotor apraxia to aphasia. Motor 
aphasias are a species of apraxias. [Stragnell.] 

Schupfer, F. Intermittent Hydrocephalus. [Riv. Crit.di Clin. Med., 

Florence. September 5, 1920.] 

Recurring periods of hydrocephalus which had come on at 10 and 
continued to 44, at monthly or bimonthly intervals irrespective of men- 
struation. She had been pregnant nine times, bearing six childen. In- 
tense headache, vomiting, dimness of vision, inability to stand lasted 
each a few days, but gradually subsided by the tenth day. The more 



214 CURRENT LITERATURE 

recent attacks have been graver, bringing transient paralysis; the blood 
pressure is high, and the optic disk congested. Lumbar puncture brings 
relief. 

Sachs, E. Brain Tumors. [Arch, of Surgery, July, 1920.] 

Of the eighty-five patients seen by Sachs, twenty-nine died, or 35.5 
per cent. Eighteen of these twenty-nine deaths were in patients suffering 
with glioma, and sixty-four, or a little more than 74 per cent., of the 
patients had tumors other than glioma, and the mortality in these cases 
was only 17 per cent. Sachs urges that every brain tumor should be 
treated on the theory that it may be a glioma, and should be grouped with 
the most urgent cases that need hospital treatment. Of the gliomas in 
his series, 26 per cent, were readily removable, though successful extir- 
pations constituted only 14 per cent. 

Salomonson, J. K. A. Wertheim. A Brain Tumor Successfully Re- 
moved. [Nederlandsch Tijdschr. voor Geneeskunde, 1920, LXIV, 
H 2, 2619.] 

Salomonson rports to the Amsterdam Neurological Society a case 
of brain tumor successfully removed in a man aged 58. He had a numb 
feeling on the back of his left forearm and hand, followed by tingling 
sensations; at first this occurred in attacks of about three minutes' dura- 
tion. Four months later, in an attack of this kind, he had a series of 
peculiar spasms and shock-movements in the fingers, lasting for three or 
four minutes, after which the fingers were quite powerless. Later, the 
attacks spread to the flexor muscles of the forearms. On the ulnar side 
of the hand tactile sensitivity was slightly affected, and there was almost 
complete astereognosis, which began definitely in the ulnar half of the 
hand and later involved the whole hand. There was a very slight but 
definite hyperemia of the right optic papilla. The diagnosis was a tumor 
of the precentral and postcentral gyri on the right side, involving the 
hand center. The tumor was successfully removed. Mention is made 
of a second similar tumor recorded by Salomonson in 1918. In the pres- 
ent case the tumor was probably a benignant endothelioma of the pia. 
Probably in both cases the tumor originated in the postcentral gyrus, 
for astereognosis appeared early and was followed by Jacksonian attacks. 
In both cases localization power and discrimination were a little dimin- 
ished. [Leonard J. Kidd, London, England.] 

Tunzen, Ezra. Differentiation of Nephrosis (Brain Tumor). [Jahrb. 
f. Kinderheilkund, 91, 1920, 51.] 

The author describes one of those rare cases of genuine chronic 
nephritis in childhood which shows at the same time the symptoms of 
brain tumor. A final judgment is not to be found, the results of a post- 



SENSORI-MOTOR NEUROLOGY 215 

mortem examination being missed. But the difficulties of differentiation 
are weighed. A healthy boy of six is suddenly taken ill, suffering with 
a nephrosis for 2% years with intervals of two to eighteen months. The 
attacks of the disease manifest themselves in form of ascites, hydro- 
thorax, anasarka, reduction of urine containing cylinders and albumin 
till 20 per cent. Whereas digitalis proves ineffective, spontaneously 
improvements set in, one time after a spinal punction, which had the 
result of an increase of the spinal pressure to 480 mm., but none of the 
liquor itself. Other cerebral symptoms are: Stanungspapille in both 
eyes, transitory paresis of nerve six, nystagmus, retardation of the pulse, 
vomits and a suprising sympanilio sound in knocking at the cranium 
(brins de pot fele). The spinal punction has no effect on those symp- 
toms. In the last three months several functions of the ascites prove 
necessary. Neither headache nor convulsions. The boy endured with 
an active mind, succumbs within four days to influenza. 

The excretion of N being undisturbed, no real uremia complicates 
the chronic nephrosis, especially with young people, but the eclamptic 
form, the symptoms of which having a striking resemblance with those 
of a quickly growing neoplasm of the cranium, in most cases in conse- 
quence of the edema of the cerebrum in highly dropsical persons. But 
neither stanungspapille nor the tympany of the skull which first made 
the suspicion of tumor cerebri rise, belong to those symptoms. 

No local symptoms of tumor being found, only those of general pres- 
sure in cerebrum, it is the question whether they only depend upon the 
nephrosis, whether the nephrosis has produced anatomical changes in the 
cerebrum or whether a tumor cerebri is coexisting with the venal malady. 
In a number of cases the coincidence of both is described and therefore 
the suspicion of a causal relationship is not to be rejected at all, espe- 
cially as the etiology of the chronic nephrosis not being clear, all possi- 
bilities must be consideered. [Author's abstract.] 

May, W. Page. Mycrogyria and its Effects on Other Parts of the 

Central Nervous System. [Brain, May, 1920.] 

A case of microgyria or arretted development of the nervous system 
is summarized as follows: Vascular lesion of the right cerebral hemi- 
sphere involving chiefly the right centroparietal region of the cortex, 
with portions of the frontal and temporal lobes and portions of the right 
basal ganglia. Atrophy and arrested development of the right pyramidal 
tract, right mesial fillet and associated structures in the midbrain, pons, 
medulla and spinal cord. Atrophy of the opposite (left) side of the 
cerebellum with some of its various nuclei and peduncles. Atrophy of 
the left side of the spinal white and gray matter. Diminution in number 
of motor cells, chiefly in the cervical and lumbar enlargements. Since 
earliest life the patient had suffered from left hemiplegia and was men- 
tally deficient. Unilateral and epileptiform convulsions of the ordinary 



216 CURRENT LITERATURE 

type were associated with the increasing deficiency. Sight and hearing 
were normal. The progression of the above symptoms terminated in the 
patient's death at the age of thirty-six years. Hemiatrophies of the 
brain are probably due originally to a vascular lesion either arterial or 
venous, occurring in fetal or early life. The chief organic changes 
result from arrested development of certain parts of the central nervous 
system. Cases of mycrogyria may be grouped according to Mott and 
Tredgold into cortical and basal classes, depending upon the situation 
of the lesion. The case described shows striking proof of the fact that 
the right half of the brain is structurally and functionally associated with 
the left half of the cerebellum and with both sides of the spinal cord, but 
chiefly the left. [Stragnell.] 

Cadwalader, W. B. Significance of Facial Pain in Determining 
the Location of Intracranial Tumor. [Am. Arch. Neur. and 
Pysch., August, 1920.] 

Pain and anesthesia of the face preceding the onset of deafness are 
symptoms usually caused by a tumor involving the gasserian ganglion. 
Neoplasms of the gasserian ganglion invariably give rise to pain or cause 
objective disturbances of sensation. Disturbances of hearing arise 
early in cases of tumor of the cerebellopontine angle. The exact order 
in which symptoms arise is of importance. A particular type of intra- 
cranial tumor which involves the cranial nerves, but does not infiltrate 
the brain substance, is known which gives rise to symptoms resembling 
those of true fibromatous tumors, but unlike these tumors, pain in the 
face is a constant symptom. [Stragnell.] 

Muskens, L. J. J. The Uncrossed Pyramidal Path. [Nederlandsch 
Tijdschr. voor Geneeskunde, 1919, LXIII, H 2, 1139.] 
Muskens showed to the Amsterdam Physico-Medico-Chirurgical So- 
ciety a young man who had been operated on six weeks previously for 
right-sided spasms and convulsive attacks some years after a wound 
of the right Rolandic region of the skull ; there was here a long scar 
involving only the skin, and the patient had continuous pain on this side 
of the head -under the scar. Muskens explained why he excluded reflex 
epilepsy. On account of the continuous pain under the scar he decided 
to explore the right Rolandic region. A local leptomeningitis was found 
with milky discoloration and thickening of the arachno'd. Unipolar 
Faradic stimulation of a zone there, of the size of a florin, provoked 
homolateral facial spasms and then a general convulsion. After the 
usual local treatment the local pain disappeared for good and some days 
after the operation there were merely slight epileptic manifestations. 
Muskens concluded that we may provisionally assume that in the numer- 
ous recorded cases of homolateral cerebral palsies an uncrossed pyra- 
midal path was present. [Leonard J. Kidd, London, England.] 



SENSORI-MOTOR XEUROLOGY 217 

van Valkenburg, C. T. A Temporal Lobe Abscess. [Nederlamlsch 
Tijdschr. voor Geneeskunde, 1919, LXIII, H 2, II 15.] 
A case of abscess of the temporal lobe was demonstrated by van 
Valkenburg before the Amsterdam Neurological 1 Society. The patient 
became somnolent a few days after operation for a purulent parotitis; 
there was also an incomplete left hemiplegia with (probably) a slight 
difficulty in findings words. An abscess of the temporal lobe was diag- 
nosed and operation was performed over the mastoid. Punctures with 
a fine trocar failed to bring away any pus, however. Death after three 
days from influenza-pneumonia. Necropsy showed osteomyelitis of the 
fore most part of the petrous bone and also extremely tenacious pus scat- 
tered in small cavities in the temporal lobe and the nucleus lentiformis. 
Doubtless the great viscidity of the pus accounted for the failure to 
evacuate any, even although the punctures were made over the site of 
the abscess. [Leonard J. Kidd, London, England.] 

Stenvers, H. W. A Postural Reflex of the Human Pelvis. [Arch. 
Neerlandaises de Physiol., 1918, II, 669.] 

Stenvers describes a hitherto unrecorded postural reflex of the human 
pelvis. The patient was a woman; her right vestibular excitability was' 
possibly slightly diminished; no palsies, but general weakness and rather 
marked hypotonia ; hyperesthetic zones on the trunk in areas of Th. 2, 5, 
7, 10; no other signs except the pelvic reflex. In the recumbent position 
she has an abnormal attitude, head turned strongly to left and inclined 
to left shoulder; trunk strongly curved, with concavity to left. The left 
leg is turned outwards and is slightly flexed at hip and knee ; the right 
leg is extended and turned a little inwards; the arms remain passive and 
are slightly flexed. On putting her in a sitting position she sinks always 
to the left and forwards. When she is lying free on the left side with 
the head strongly bent and turned to left, she executes a very compli- 
cated movement when she is asked to turn over on to the other side; 
she begins by inclining her head very strongly backwards so that the 
occiput is buried in the pillows ; then she turns the pelvis to the right 
and immediately the head turns to the right with an abrupt jerk, after 
which the shoulders follow. When the pelvis is immobilized she cannot 
turn ber head to the left. On attempting to turn back to her left side, 
her pelvis being left free, she begins afresh by turning her pelvis to left, 
and immediately her head and shoulders follow with a jerk. Thus, the 
rotation-movement of the body is introduced by the pelvis, the head 
following this movement abruptly, as l»y a reflex effect. Rotation of the 
head can be provoked also by passive rotation of the plevis. One firmly 
immobilizes her shoulders and asks her to remain absolutely passive. 
Then, while she is lying half on her side, one changes her pelvis from 



218 CURRENT LITERATURE 

one position to the other; immediately her head makes a violent, abrupt 
movement in the sense that it always maintains its normal position in 
relation to the pelvis, the sagittal line of the cranium being placed per- 
pendicularly to the line which connects the heads of the femurs, while 
the occiput is turned towards the back. (The reflex remained constant 
for four weeks.) When the pelvis is passively rotated, the head being 
fixed, the eyes deviate strongly in the direction of the pelvic inclination, 
but without nystagmus. When the pelvis is held in position, the patient 
lying on her back and her head turned to left, one finds that if her left 
shoulder be slightly raised her head turns to the right with a jerk, but 
she inclines more strongly towards the back than when the pelvis is 
rotated. Stenvers' reflex can be elicited also, but feebly, when the back 
is not resting on the bed. He draws attention to the resemblance of his 
reflex to that described by Magnus in the rabbit whose brain has been 
removed proximally of the thalamus, the labyrinths being left intact. 
[Leonard J. Kidd. London. England.] 

Gordon, Alfred. Abscess of the Occipital Lobe. [Phil. Neur. Soc, 
Feb. 25, 1921.] 

E. T., male, aged 36, born in Italy, a veteran of the last war, was 
wounded during the war in the right arm and stabbed in the left hypo- 
chondriac region posteriorly. He recovered from those wounds. In 
October, 1920, patient developed severe headache over the temporo- 
frontal region on both sides. At first the headache was intermittent, 
but of late became persistent and unusually severe. The pain soon 
extended to the left auricular region. During the last two months he 
has had very frequent attacks of dizziness followed by fainting spells 
which occurred two or three times a day. He has had also frequent 
attacks of vomiting, especially in the morning. 

An objective examination reveals the following condition. There is 
not a very pronounced but distinct weakness on the right side. He per- 
forms movements with his right arm and leg, more sluggishly than with 
the left 'extremities. The knee jerk, flexor and extensor reflexes of the 
right arm are somewhat more marked on the right than on the left side. 
There is no ankle clonus, no Babinski on either side but there is a dis- 
tinct and easily obtainable paradoxical reflex on the right side. When 
the left side is tested for the latter reflex, a contralateral extension of 
the right great toe is evident. The absence of the Babinski and the pres- 
ence of the paradoxical sign have been manifest from the beginning of 
his malady, before as well as after the operation. The abdominal and 
cremasteric reflexes on the right are exceedingly slight and sometimes 
not at all obtainable on the right side, while they are distinct on the left 
side. The patient's gait is uncertain, there is a certain amount of 
asynergia as the trunk did not altogether follow the legs; the patient 



SEXSORI-MOTOR NEUROLOGY 210 

did not hold himself erect in walking. He swayed somewhat from side 
to side. He was unable to stand on either foot. Adiadokokinesia was 
not present. There was no ataxia in the finger-to-nose movement or 
in the past-pointing test. There was only a sluggishness in the move- 
ments of the right arm as mentioned above. Test for sensations re- 
vealed the presence of all forms but they were somewhat increased in 
the right arm and leg. particularly with regard to pain. The deep sensi- 
bilities were all intact. Asclereognosis was not present in the right 
hand or foot. 

The eye examination showed slightly unequal pupils, right 4 mm., 
left 3 mm. The eye grounds were normal. There was a distinct right 
lateral homonymous hemianopsia. The latter existed from the onset of 
the disease. 

Examination of the blood and spinal fluid was negative. 
Urinalysis was negative with the exception of occasional traces of 
albumin and hyalin casts. 

Blood examination showed fl. 75 per cent., red bells 3,190,000, white 
cells 17,000, blood urea .025. blood urea nitrogen .on. 

A Barany test gave variable and consequently no definite data to 
form an opinion as to the localization of the lesion. 

The patient presented no previous special medical history with the 
exception of the above mentioned injury during the war. He is mar- 
ried, has two children; the wife had no miscarriages. 

Comment. — To sum up. the patient presents a very mild hemiparesis 
on the right side with hyperalgesia on the same side, also right lateral 
homonymous hemianopsia. That the paresis was of organic nature is 
evident from the presence of an increased knee jerk and persistent para- 
doxical reflex on the same nature is evident from the presence of an 
increased knee jerk and persistent paradoxical reflex on the same side in 
spite of a persistent absence of Babinski's sign. These facts and par- 
ticularly the hemianopsia led the writer to conclude that the lesion was 
probably in the left hemisphere and in its optic radiations. The lesion 
produced pressure or irritation forward on the posterior limb of the 
internal capsule, irritating the sensory and motor portions of it, thus 
producing the hyperalgesia and the weakness on the right side, also the 
paradoxical reflex with a somewhat increased patellar tendon reflex. 

In view of the history of headache of an unusual severity, also of 
dizziness and vomiting, the presumption was in favor of a neoplasm in 
the above area. An operation by Dr. Behrend over the occipital region 
exposing the posterior portion of both occipital lobes revealed an abscess 
in the left occipital lobe involving the entire lobe. The case is interest- 
ing from the following standpoints: 

The presence of hemianopsia which more than anything else led to a 
correct localization of the lesion. 



220 CURREXT LITERATURE 

The persistence of the paradoxical reflex at the persistent exclusion 
of the Babinski sign. 

The association of the paradoxical reflex with an increased knee jerk 
and a paresis on the right side. 

The presence of hemihyperalgesia showing irritation of the " carre- 
four sensitif " of Charcot. 

The right-sided symptoms were rather of an irritative than of a 
destructive character. In the latter case the result would have been 
complete hemiplegia with hemianesthesia and a distinct Babinski reflex. 
The few cerebellar manifestations, such as the asynergia, the oscilla- 
tione of the body from side to side while walking can be explained by the 
pressure exercised upon the cerebellum from the above situated abscess. 

A lesion, therefore, of the occipital lobe may simulate a cerebellar 
disease, thus making the localizing diagnosis difficult. [Author's ab- 
stract.] 

Casamajor, L. The Diagnosis of Brain Abscess. [The Laryngoscope. 

1920, XXX, July, p. 436.] 

The difficult subject of the diagnosis of otic brain abscesses is here 
lucidly discussed. Its difficulty depends on the common inability of the 
patient to cooperate, the severity of the disease and its usually short 
course. Temporosphenoidal and cerebellar abscess preponderate greatly 
over other forms. Otogenic brain abscess has three fairly definite 
stages: (1) the initial or invasion. (2) the latent, and (3) the stage 
of manifestations. The initial stage varies in duration and may be lack- 
ing; when it is present, there are commonly cerebral signs; fever may 
be present or absent; the commonest cerebral symptoms are headache, 
vomiting and clouded consciousness; the headache is usually general, 
but may be on the side of the lesion ; vomiting occurs more in cerebellar 
than in cerebral abscesses; mental clouding may vary from slight confu- 
sion up to severe stupor or delirium ; signs of meningeal irritation may be 
present. This stage lasts usually for twelve to twenty hours, but may last 
a week. The lateral stage is very variable, may even be absent or may 
last for days, weeks or over a year. The symptoms of the preceding 
stage more or less disappear and recovery from the cerebral irritation 
appears to have set in, but the abscess is now forming as a localized 
lesion, and with its growth symptoms of the third stage may appear 
slowly or with startling suddenness. In the stage of manifestations 
there are usually general symptoms, due to the disease and brain pres- 
sure from the abscess and surrounding edema; and local symptoms, due 
to destruction of and pressure on structures close to the abscess. Among 
general symptoms fever is often absent and the temperature ma) r be sub- 
normal throughout; there may be an evening high temperature with 
chills. If the abscess bursts into the meninges or the ventricles, con- 
tinued high fever is the rule. Headache is constant, may be on the side 



SENSORI-MOTOR XEUROLOGY 221 

of the lesion, is seldom over the site of the abscess, may be hemicranial, 
and may in cerebellar abscess be frontal. The position of the headache, 
even when the skull in the region of the abscess is tender on percussion, 
is unreliable for localization. Projectile vomiting is seen especially in 
cerebellar abscess. Slowing of pulse, even with moderate fever, is a 
frequent and valuable diagnostic sign; so is slowed respiration. The 
pupils are of no value in diagnosis. Choked discs occur in only a mi- 
nority of cases. Okada says optic neuritis without papilledema is much 
commoner than choked discs. Convulsions, general, hemi, or local, 
occur with many large abscesses. Consciousness is always disturbed, 
from slight drowsiness and confusion to coma and delirium; this pre- 
vents cooperation on the patient's part and so adds to the difficulty of 
examination. The local symptoms are often meager and may be absent. 
Temporosphenoidal abscess, the commonest of all brain abscesses, has 
the least definitely localizable signs, especially if right-sided. A large 
right abscess may give left homonymous hemianopia, but the mental 
state of the patient may prevent its discovery. In left temporosphenoidal 
abscess speech disturbances, chiefly paraphasia, are present, with diffi- 
culty in understanding of speech ; this adds to the difficulty of diagnosis. 
In cerebellar abscess localized signs are usually definite ; the patient lies 
with head turned back or to the side of the lesion ; often there is neck- 
stiffness; on sitting up the patient has increased headache and often he 
is dizzy. In standing he takes a broad base ; gait is unsteady and 
asynergic; he may fall to either side. The hands, when elevated, cannot 
be kept up, but drop suddenly, the one on the side of the lesion oscillating 
must as it falls. Nystagmus, when present, is towards the side of the 
lesion. The tendon jerks are usually diminished or lost. Babinski's 
sign is rarely present. All movements of the homolateral limb, when the 
patient is reclining, are asynergic. The patient past-points usually 
towards the diseased side. With the asynergia, adiadokocinesis is usu- 
ally present. Early diagnosis of brain abscess is essential for good 
surgical results. Our great difficulty is to localize the abscess. [Leon- 
ard J. Kidd, London, England.] 

Hoffmann, Hermann. Brain Tumor in Two Brothers. A Contribu- 
tion to the Heredity of Tumors. [Zeitschr. f. d. ges. Neurol, u. 
Psychiat, 1919, Vol. 51, p. 113.] 

The author describes the cases of two brothers in whom tumors sit- 
uated in the same organs produced similar symptoms. One of the cases 
was personally observed and the case history of the other was accessible 
to the author. The essentials of the cases were that two brothers, one 
three years older than the other, the elder at the age of 33 years and 
the younger at the age of 48 developed symptoms of brain pressure. In 
hoth cases diagnosis of tumor was made, and the autopsy revealed in 



222 CURRENT LITERATURE 

each a glioma rich in cells which, in the one brother took in the left 
gyrus hippocampi and occipito-temporalis and reached up to half of the 
temporal lobe; and, in the other, was limited to the right hippocampus 
and gyrus hippocampi. The family history showed that the father in 
the later years of his life had suffered from epileptic seizures which had 
finally resulted in death. When collateral members of the same family 
develop similar diseases heredity may be assumed with great show of 
probability, and all such cases of tumor go to confirm the view first 
advanced by Thiersch and Cohnheim that the factor of heredity in the 
etiology of tumors is of great significance. In the author's cases the 
only positive indication of heredity consists in the great similarity be- 
tween the father and the two sons; the fact that the disease was limited 
to the male members of the family was also noteworthy. The main in- 
terest attaching to this case is that it is a contribution to the material on 
the heredity of tumors. [J.] 

Souques, A. Cranial Traumatism and Tuberculoma of the Brain. 
[Revue Neurologique, January, 1920. Soc. N. et P., January 8, 
1920.] 

A history of trauma to the parietal region followed by headache was 
later followed by sypmtoms of increased intracranial pressure, Jack- 
sonian epileptic attacks, etc. Autopsy showed a tuberculoma in the 
brain beneath the part of the skull struck. [Camp.] 

Duofur, H., and Semelaigne, G. The Nature of the Cellular Ele- 
ments in the Cerebrospinal Fluid in a Sarcoma of the Brain. 
[Revue Neurologique, January, 1920. Soc. de N. de P. Seance, Jan- 
uary 8, 1920.] 

The presence of peculiar cells in the cerebrospinal fluid of cases of 
tumor of the brain first recorded by Dufour in 1904 has been noticed by 
many observers, Leri and Catola, Sicard and Gy and others. They are 
large round cells difficult to identify histologically. In some cases they 
have appeared to be identical to those subsequently found to compose 
the tumor. In the case reported the patient, aged 22, had generalied 
convulsions, headache, somnolence and right sided facial palsy. There 
was a left sided ankle clonus and a horizontal nystagmus. Hearing was 
defective on the right side on account of otitis media. Ophthalmoscopic 
examination showed some edema of the upper and external portions of 
the nerve head in the right eye. The spinal fluid was yellowish, con- 
tained an excess of fibrin and globulin and numerous red blood cells, 
leucocytes, some leymphacytes and some large round cells with a deeply 
stained nucleus and pale protoplasm which was frequently granular or 
vacuolated. Autopsy showed a tumor the size of an orange in the 
parieto-occipital region growing from the meninges. The tumor was 



SENSORI-MOTOR NEUROLOGY 223 

firm and circumscribed and was microscopically a spindle cell sarcoma. 
The cells in the spinal fluid were totally different from the spindle cells 
in the tumor. [Camp.] 

Winkler, Junius E. The Histogenesis of Glioma Cerebri and the 
Difference in Structure between Glioma Tissue and Reactive 
Neuroglia. [Psychiat. en Neurolog. Bladen, 1920, Nos. 3-4, May- 
August, p. 196 (25 figs.).] 

The writer's first case, a neuroglioma cerebri, showed a tissue com- 
posed of small oval cells, directed more or less parallel to one another, 
and for the most part without evident protoplasmic processes. They lie 
in an interstitial substance formed of a wide-meshed network of fine 
glia fibers sparingly interrupted here and there by blood vessels. Cavi- 
ties, whether or not lined by epithelium, occur only in the immediate 
neighborhood of the ventricles. The normal protoplasmic syncytium 
has disappeared, and such medullary sheaths as are found are swollen 
and the vessls have a wide lumen and thin walls. Doubtless we have 
here a true neuroglioma. belonging to the category of glioma durum on 
account of its little tendency to softening, lack of hemorrhages and its 
strongly developed stroma. Its circum-ventricular site shows that it 
belongs to the central gliomas. In this case there were no large cavities ; 
only immediately around the ventricle of the occipital cornu, where there 
was no tumor tissue present, were there many small cavities lined with 
ependymal cells; one of these contained numerous invaginations of the 
ventricular wall, lined with ventricle epithelium, so that the writer can- 
not but regard the small cavities as transversely cut ventricular invagi- 
nations. On following the ependyma forwards to the frontal lobe 
where the tumor has its greatest extension, one finds everywhere these 
ependymal invaginations, with a many-layered ependyma and multi- 
nucleated ependymal cells. It is possible to regard these foldings of the 
ventricular wall as a developmental anomaly. The frequent occurrence 
of places where the ependyma has five or six layers, the numerous groups 
of ependymal cells, the occurrence of many invaginations in the sur- 
rounding tissue, and finally the multi-nucleated ependymal cells, all this 
points rather to a proliferative process. That this proliferation cannot 
be interpreted as a reaction of the surrounding tumor tissue is shown by 
the fact that in proportion as the tumor decreases the ependymal pro- 
liferation increases, and that the latter is at its maximum in the occipital 
region where no tumor tissue is. present. A section around the ventricle 
at the hinder border of the tumor shows how the ependymal cells, re- 
leased from their normal relation, arrange themselves in many layers, 
and how by their more oblong nucleus and their possession of fibrous 
protoplasm they appear to pass over into glia cells. The presence of 
these transitional cells and the fact that the ependymal proliferation is 
greatest where no glioma tissue is formed, renders it probable that these 



224 CURRENT LITERATURE 

ependymal changes must have the meaning of a primary proliferation 
which directly precedes the formation of the gliomatous tissue, and not 
of a developmental anomaly. The tumor is. then, a gliomatous neuro- 
epithelioma, and it should have a place in the series of tumors between, 
on the one side, the true ependymal tumors which grow out of the ven- 
tricular cavities and contain cells of more or less ependymal shape, and 
on the other side the true gliomata. 

In the case of a child, which was diagnosed as glioma cerebri, Cajal's 
glia method was used with the result that a preponderance of large glia 
cells with numerous processes was found. Further histological exami- 
nation showed that there were many perivascular infiltrates, a multitude 
of anatomical glia cells and groups of Gram positive bacteria, so that 
an encephalitis was established. (A similar condition is figures of the 
end-stage of an experimentally produced encephalitis in a cat). As to 
the distinctions in structure between the glioma cell and the reactive 
glia cell, the writer points out that the former lacks certain qualities that 
are exactly characteristic of the latter. The reactive glia cell has a 
polygonal shape, with a great development of protoplasm and a rela- 
tively small nucleus that is almost always ex-centric; further, it has 
generally definite protoplasmic processes which develop in a certain 
direction, dependent on the situation of the cell with regard to the focus 
or the blood vessel causing the reaction; the majority of the largest 
processes are directed towards the focus. In a further stage the fibrils 
develop out of the protoplasm, not regularly around the nucleus, but 
locally on the cell periphery, at first separated as far as possible from 
the centric nucleus. This homogeneous protoplasm then becomes re- 
ticular, or one sees a network of fine fibers which send in protoplasmic 
processes, parallel to one another and form a fiber bundle. (A couple 
of cells are figured, showing a fibrillogenous zone.) The glioma cell, 
on the contrary, has a relatively large nucleus or many nuclei, and a 
regular, nonangular, rounded shape, which is brought about by the uni- 
form development of its protoplasm around the nucleus ; and there appear 
to be no stimuli from the surrounding tissue which could influence this 
development. At most one sees around necrotic areas in the tumor that 
this shape is modified and that the glioma cells which surround the focus 
have directed their greatest protoplasmic development towards it. There 
is also a difference in fiber-course between reactive glia tissue and 
glioma tissue; in the reactive glia cell the fibers are formed from one or 
more peripherally situated zones; the fibers near the focus retain this 
relation with their cell for a long time. If the reaction of the glia cell 
be limited to small foci, one sees that the fibers mainly converge towards 
the focus, the glia cell reacts to an extensive process, such as an en- 
cephalitis, and then the fibers run out of the cell in all directions. The 
writer explains the polygonal shape of these cells as due to an irregular 
stimulation of the surface of the cell by the presumable external chem- 



SEKSORI-MOTOR XEUROLOGY 225 

ical agent, the fibrillogynous zone of the cell being at each angle (this 
is figured). 

The course of the fibers in glioma tissue is quite different: first, the 
protoplasm of single cells, or the protoplasmic syncytium that contains 
many nuclei, takes on a fibrillar structure, which is uniformly distributed 
over the protoplasm, as in a pons glioma figured here. At a further 
stage one sees parallel-running fibers take the place of the protoplasm, 
as in a cortical glioma figured. For the most part there are no sharp 
cell boundaries and gradually this stage passes into the following one in 
which the cells have set themselves free from the fibrous protoplasm and 
the fibers form a network of smaller or larger meshes. The relations 
also of the reactive glia cell and of the glioma cell to the blood vessels 
are different; the former seeks a connection with the neighboring vessel, 
whereas the latter is not influenced by blood vessels in the development 
of the plasma and the fibers. At one time the fibers run parallel to the 
blood vessel, then, running always in bundles, they make an angle with 
the course of the vessel ; in short, the glioma cell lacks all the individ- 
uality which the reactive glia cell has in relation to its surroundings. 
Among the gliomas examined by the writer was one of the thalamus, in 
which necrotic areas alternated with gliomatous tissue ; as to whether 
the old inflammatory foci were primary and had led to a reaction of the 
surrounding glia, or whether these necrotic areas existed in the primary 
gliomatous tissue, he favors the latter opinion on account of his histo- 
logical investigations just described. He thinks that the histological 
distinctions described by himself may be of diagnostic value in further 
cases. [Leonard J. Kidd, London, England.] 

Neel, A. V. Brain Tumors. [Ugesk. for Laeger., July 8, 1920.] 

The author's five cases of brain tumors are used to maintain the gen- 
eral argument that a previously healthy person does not suddenly develop 
neurotic syndromes without some real etiological factors, somatic or 
psychogenic. One of the patients was long treated for nervousness until 
the blood picture indicated serious changes and a mammary cancer 
metastasis was uncovered. In two of the patients motor twitchings and 
spasms had preceded other symptoms of brain tumor by nearly six years. 
Striking remissions in the clinical course of a brain tumor are liable, he 
says, and points out that psychogenic factors must always be reckoned 
with, x ray treatment even showing typical suggestion reactions. 

Frazier, C. F. Effects of Radium I'm a nations on Brain Tumors. 

[Surg. Gyn. and Obstet., September, 1920.] 

In three only of twenty-four patients with brain tumor subjected to 
radium emanations there seemed to be indisputable evidence that by 
radium emanations the growth of the tumor has been arrested and in 
all probability the tumor destroyed. See Report New York Neurological 
Society. December, 1920, this Journal. 



226 CURRENT LITERATURE 

7. EPILEPSY. 

Bambaren, Carlos A. Present Ideas Concerning the Etiopathogene- 

sis and Treatment of the So-called Essential Epilepsies. [ Anales 

de la Facultad de Medicina de Lima, 1920, Vol. 3, January-February, 

p. 14; March-April, p. 118, and May-June, p. 221.] 

Epilepsy is not a single morbid entity as was formerly supposed. The 
division of types begun by Bravais and Jackson has been continued and 
a better understanding of the causes of the convulsive seizures has 
shown "essential epilepsy" to be a mere symptom. There is no longer 
an epilepsy; there are epilepsias. Numerous etiopathogenic causes as 
syphilis, alcoholism, infections, traumatisms, etc., give rise to meningo- 
encephalic processes resulting in anatomopathological lesions. These 
play an important role in producing epilepsy, which for this reason is 
not "essential," but cerebral. With these cases of cerebral epilepsy 
must be contrasted those due to endocrinopathies, which alone in any 
way merit the epithet essential and the only provisionally, so long as the 
anatomopathological factor responsible for them remains undiscovered. 
In this type of epilepsy the disturbances apparently stand in some rela- 
tion with chemical anomalies in the organism. Those endocrinopathic 
convulsions with cranioencephalic disturbances, usually of the pituitary 
gland, are symptomatic cerebral epilepsies. The predominance of thy- 
roid and parathyroid disturbances in noncerebral epilepsies and the good 
results which follow opotherapy is very significant. Following these 
views the various epilepsies may be classified as: (A) convulsive, and 
(B) nonconvulsive, i.e., those with equivalents and other forms which 
fall under this concept. The convulsive epilepsies may be divided into : 
(1) cerebral epilepsies, in turn subdivided into localized types (of 
Bravais-Jacksonian character), and general types (infectious, toxic, 
traumatic, teratopathic and neoplastic). (2) Endocrinogenic epilepsies, 
or those provisionally considered essential, in turn subdivided into those 
due to primary thyroid and parathyroid abnormalities and those due to 
secondary disturbances of these glands, or the pluriglandular syndromes. 
The marginal gliosis found in the cerebrum is not to be regarded as an 
idiopathic anatomopathological lesion, but as due to proliferations of the 
glia following histolysis of the cerebral produced during the convulsive 
crisis. The original seat of the convulsive manifestations is the cerebral 
cortex, conclusively demonstrated by the Abderhalden reaction. In the 
mechanism of epileptic seizures physicochemical phenomena of colloidal 
nature intervene, in virtue of which toxic albuminoid products are 
formed which inhibit certain cerebral cellular activities and permit infe- 
rior mechanisms of kinetic character to enter into activity. The thera- 
peutics of epilepsy should be individual and should be directed both 
against the cause of the disease and the symptoms. In each case the 
causal factor may be different and the symptoms are very diverse. Spe- 
cifics should be used against the morbid agent, opotherapy against the 






SENSORI-MOTOR NEUROLOGY 227 

functional disturbances, together with nonspecific antigen therapy. The 
symptomatic treatment with bromide according to the method of Richet 
and Toulouse has proved very beneficial. 

Alikhan. Hereditary Anosmia and Epilepsy. [Rev. de Laryngol., 

d'Otol., et de Rhinol., 1920, June 15, 330.] 

In a family of thirty members there were eleven anosmatics, four 
hyposmatics and two epileptics; the transmission was by females, them- 
selves anosmatic. The writer made olfactory tests on eighteen epi- 
leptics; in all there was either a great diminution or loss of olfactory 
perception to stimuli from rose, asafetida and alcoholic extracts; to 
acids and alkalies all the patients, save the dements, reacted, but they 
experienced only an irritative sensation. Alikhan concludes that hypos- 
mia or anosmia occurs in epileptics, not merely after the attacks, as Fere 
held, but also during the intervals. He refers to the fact that sclerosis 
of the cornu ammonis, an olfactory center, has very often been found in 
epileptics. He does not think that the hyposmia of epileptics is a mani- 
festation of dementia, for in a series of cases of general paralysis and 
of dementia praecox he found normal olfactory power in most of them. 
[Leonard J. Kidd, London, England.] 

Marsh, C. A. A Psychological Theory of the Cause of Epilepsy. 
[American Journal of the Medical Sciences, March, 1920.] 
The author concludes that we must look upon epilepsy as an abnormal 
muscular reaction to strong emotional states. It is an abnormal ex- 
pression because such muscular activity does not gain the end for which 
the emotional state was generated. It is unnatural since its effort- is 
undirected. The epileptic, because of his peculiar makeup, cannot avoid 
the dangers of too great stress as the normal man meets it, but, by an 
emotional drive that cannot be readily checked, labors on to mental 
exhaustion in unconsciousness. This is not deep enough to involve the 
motor or life centers of the brain, so a convulsion takes place. Viewing 
epilepsy in this light, the author thinks that we are now able to institute 
more rational methods of treatment than have been found in surgical 
procedure and in empirical therapy. 

Wallon, Henri. Emotion and Epilepsy. (Societe de psychologic Meet- 
ing of January 29, 1920.) [Journal de Psychologic 1920. April 15. 
Vol. 17, p. 307.] 

Epilepsy has not long been counted among those diseases which are 
supposed to exist without perceptible organic lesions. Formerly patients 
and those about them had often attributed the outbreak of the seizures 
to emotional incidents but little credit was given by physicians to these 
histories. Experiences in the war. however, have furnished objective 
confirmation of the origination of the disease in emotional shocks, though 



228 CURRENT LITERATURE 

as Leri notes the emotional origin is now likely to be denied by the 
patients. Nearly all those who, without having been wounded, have suf- 
fered war injuries claim to have been " shocked," because it seems more 
creditable to have succumbed to the brutal force of war engines than to 
mere emotions, but numerous instances seem to prove that in the absence 
of shell explosions near the patient these ictuses can only be due to fear 
or epilepsy. In citing cases the author observes that usually epilepsy 
activated by emotion occurs only in individuals who present signs indi- 
cating predisposition to paroxysms convulsive seizures. In one of the 
cases cited by the author emotion led to unconscious states resembling 
phases of epileptic seizures but also with similarity to those emotional 
stuporous crises which were frequently encountered in war experiences. 
Passages from these emotional reactions to epilepsy does not seem im- 
possible. The participation of organic functions are more manifest in 
emotions than in any other psychic state. Long continued or violent 
emotions are followed by disturbances which M. G. Dumas has shown 
are caused by intoxication. According to F. W. Mott the attitudes and 
reactions accompanying each emotion are due to a discharge of endo- 
crine products into the organism, and Pieron has insisted on the hyper- 
thyroidism and hyperrenalism in emotional states. Epileptic manifesta- 
tions also, by their form and course, suggest a toxic origin. If the 
granulations with which Nageotte has shown the neuroglic filaments may 
be charged are indication of innersecretory activity, the hypertrophy of 
the neuroglia in the brain of epileptics might indicate a relation between 
epilepsy and the endocrine functions. The intensity of the circulatory 
disturbances in the emotions and in epilepsy also suggest a mechanism 
by which the one might degenerate into the other. Further every emo- 
tion of any degree of liveliness or duration is quickly translated into 
motor reactions, which are only retarded by efforts of inhibition. For 
this reason Pieron asks if they do not indicate essentially disturbances 
of association of the nature studied by Lapicque under the name of 
chroniaxia. The spasmodic phenomena and especially the asynergias 
expressed in trembling, giving way of the limbs, stammering, aphony, 
incontinence of urine and convulsions are a series of transitions which 
suggest the possible transformation of anemotional crisis into an epi- 
leptoid seizure. The type of person predisposed to attacks of this nature 
would be those inclined to spasms and motor incoordinations, or to circu- 
latory instability and excitability of reflexes which go to make up the 
emotional character — all peculiarities depending quite as much on the 
trophic condition and developement of the organs as on the constitution 
of the psyche. It is because of the violent organic reactions in emotions 
that their influence in the production of epilepsy seems possible. [J.] 



SE.XSORI-MOTOR NEUROLOGY 220 

Bratz. The Hippocampus Major in Epileptics, Paralytics, Senile 
Dementias and Other Sufferers from Mental Disease. [Mo- 
natsschrift fur Psychiatrie und Neurologic January, 1920.] 
The writer studies the occurrences of involvements of the hippocam- 
pus major in various forms of mental disease. Sclerosis of the hippo- 
campus major is diagnostic for epilepsy, as well as for idiocy combined 
with epilepsy, and also for progressive paralysis. It never occurs in 
schizophrenics in whom attacks of dizziness and convulsions are ob- 
served, nor in acute febrile and exhaustion psychoses. [Stragnell.] 

Redlich, Emil. Epilepsy after Gunshot Wounds of the Skull. 
[Zeitschr. f. d. ges. Neurol, u. Psychiat.. 1919, Vol. 48, p. 8.] 
The results of the careful clinical observations of 57 patients with 
epileptic attacks after skull wounds is discussed and the author endeavors 
to draw conclusions therefrom concerning the pathology and pathogene- 
sis of epileptic attacks. In cases after wounds, much more frequently 
than in ordinary epilepsy, the specific causes of the seizures can be deter- 
mined. Thermic stimulation was repeatedly tested and it was found 
that while the warm applications produced unpleasant sensations, in the 
majority of the cases attacks did not ensue. In one case a seizure was 
produced by the alternate application of hot and cold to the break in the 
bone and in this case, contrary to the condition in Trendelenburg's ex- 
periments with animals, the resistance of the cicatrice, which is a bad 
conductor of heat, had to be overcome. The author thinks these facts 
prove that it is possible for epilepsy to result from sunstroke. In some 
cases the seizures could be caused by strong sensible stimulation in the 
paretic member. The Jacksonian type of seizures was the most fre- 
quent. Epileptoid conditions and psychic equivalents were not observed. 
For the most part the attacks began in an extremity — usually one rela- 
tively slightly paralyzed, for if a brain center is too severely injured it 
can no longer be a factor in producing convulsions. In three cases ex- 
traparoxysmal twitching and in one " epilepsia continua " was noted. 
In 50 of the 57 cases neurological effects were in evidence and in 48 
cases these disturbances were referable to the mortor cortx. Grave 
psychoses were not observed, and there were no instances of the " epi- 
leptic character." The psychic disturbances — episodic depression, irri- 
tability, apathy, disturbances of attention and intellect were, in general, 
no more marked than in those cases of skull wounds in whicb tbere were 
no epileptic seizures. In contradiction to Poppelreuter and in confirma- 
tion of Goldstein the author did not find heightened blood pressure in 
the majority of cases. Leucocytosis was most frequent in cases with 
general convulsions and there was no evidence in favor of the signifi- 
cance of the epileptic predisposition, which is claimed by most writers 
to be very important even in traumatic epilepsy ; further he did not ob- 
servea single case of " reflex epilepsy." Wounds localized in the motor 



_\?o CURREXT LITERATURE 

region were more often followed by epilepsy than those in other re- 
gions, the percentage being 63.7. In skull wounds without epilepsy this 
localization was observed in only 40-45 per cent, of the cases. After 
injuries of the parietal lobe 91. 1 per cent, had Jacksonian type of seiz- 
ures. Lumbar puncture, which was undertaken in only a few instances 
because of the unpleasant results (production of attacks), gave no indi- 
cation of cerebrospinal pressure. No results could be attributed to the 
presence of splinters in the brain but the malformation of the cicatrice 
seemed to be a factor in causing attacks, especially in the motor region. 
In general the pathologico-anatomical character of these cases seemed 
to differ from those cases of skull wound without epilepsy only in degree, 
or in the localization of the wound. Or perhaps the difference consisted 
only in the fact that in the cases observed the attacks made their appear- 
ance earlier and it may be that later epilepsy made its appearance also 
in some of the other cases. The results of surgical intervention was 
not satisfactory in the author's cases. He never observed the complete 
disappearance of the seizures, and the covering of the bone defect was, 
according to his experience, inadvisable. [J.] 

Marchand, L. Epilepsy and Hysteria. [Presse med., September 8, 

1920.] 

Associated epilepsy and hysteria frequently occurs according to the 
author who maintains that treatment must be differentiated. He reviews 
the older literature on this combination. 

Buchanan, J. A. Hereditary Factors in Epilepsy. [Minn. Medicine, 

November, 1920.] 

All of the 128 cases of essential epilepsy analyzed by Buchanan had 
normal or approximately normal blood pressure and negative Wasser- 
mann tests, and all had negative sella turcica findings or other cranial 
evidences of definite significance. The examinations of the eye grounds 
were negative. Examination of the spinal fluid was made and found to 
be negative. In none of the cases was a cause for the convulsions 
found. 10.9 per cent, of the patients had a direct or indirect history of 
epilepsy in the family. One only had a child that was epileptic. Mi- 
graine was present before the onset of epilepsy, and alternated with or 
continued with epilepsy in eighteen (14 per cent.) of the cases studied. 

Masoin, Paul. The Diazo Reaction in Epilepsy. [Bulletin de l'Acad- 

emie Royal de Medecine de Belgique, July, 1919.] 

Masoin has here discussed the diazo reaction of the urine in cases 
of epilepsy. The diazo reaction was not obtained with average urine. 
He finds (a) the diazo reaction in epileptics is an indication of a general 
upset, which affects most of the urinary excretions and in particular the 



SENSORI-MOTOR NEUROLOGY 231 

excretion of nitrogen, (b) This fact is an argument in favor of the 
view that certain forms of epilepsy result from a state of autointoxica- 
tion, a true disturbance of cell metabolism. Absence of a diazo reaction 
in epilepsy justifies a favorable prognosis; the presence of the reaction 
implies a fatal prognosis in two thirds of cases. The diazo reaction, 
which appears on the occasion of epileptic parovysms. is an indication 
of a disturbance which affects the nutritive exchanges of the subject. 
In spite of the semeiological insignificance with which this reaction was 
first viewed, it seems to be a demonstration in the mechanism of cellular 
metabolism. The view that epileptic crises are the result of intoxication 
by ammonium carbamate is discussed and it is pointed out that the in- 
toxication with ammonium carbamate is probably excessively slow as 
compared with the rapidity of onset of an epileptic attack and the rapid 
evolution of the symptoms. 

Jellinek. S. The Diagnosis of Epilepsy. [Wien. med. Woch., No- 
vember 1 and 8, 1919.] 

Two sjgns of epilepsy — the presence of Babinski's reflex and the 
occurrence of petechiae and ecchymoses in the skin and mucous mem- 
branes are discussed especially by Jellinek. Babinski's reflex is present 
during the attack, and often this persists for three-quarters of an hour. 
In many cases after reflex was exhausted Oppenheim's sign could be 
observed especially after attacks of petit mal. Petechiae. though not 
found so regularly as Babinski's sign, occurred in nearly half of the 368 
epileptics observed by Jellinek. They were most frequently found in 
the upper lids, but in many cases upper and lower lids were sprinkled 
over with petechiae. The root of the nose and forehead, and even the 
frontal scalp and temples had them. 

Clark, L. Pierce. A Psychological Interpretation of Essential Epi- 
lepsy. [Jr. Am. Med. Sc, May, 1920.] 

The causation of essential epilepsy is dependent upon a primary con- 
genital defect or inheritable defective instinct of natural and healthful 
adaptations to reality; producing the epilepic makeup or constitution. 
At successive periods in life, early infancy, nursery days, puberty and 
adolescence, when intensive emotional and psychic stresses are encoun- 
tered, the potential epileptic has epileptic reactions such as fits, temper 
outburst, lethargies and various psychic phenomena. The fit is a re- 
gression, a flight into unconsciousness from undue stress. The convul- 
sive phenomena resemble somewhat the impulsive movements of the 
fetus and nursling, and are the deeper manifestations of unconsciousness. 
The depth of the regression and the infantility of the individual may be 
studied by analysis of the states of automatism, conscious analysis, and 
dream states. The proper treatment of epilepsy is not by sedatives but 
by intensive and persistent educational training, together with the cor- 



232 CURRENT LITERATURE 

rection of mental and physical disorders that can be remedied by occu- 
pation, educative play and healthful interests. 

Van Valkenburg, C. T. The Position of So-called Genuine Epilepsy. 
[Psychiatrische en Neurologische Bladen, 1915, Nos. 4 and 5.] 
Basing his observations on material gathered from a hundred epi- 
leptics studied in the clinic, the writer proves that genuine and sympto- 
matic (cerebral) epilepsy present, from a constitutional point of view, 
absolutely the same features. Lefthandedness, stammering, hemicrany, 
nocturnal enuresis are equally frequent in both forms, in the patient 
and his family. Epilepsy and convulsions appear with the same fre- 
quency in the relatives of both groups. There is no difference in the 
results of Abderhalden's reactions. No differentiation can be made be- 
tween organic and genuine epilepsy. The only certain etiology consists 
in a cerebral lesion, intrauterine in origin. It is very probable that some 
difficulties of metabolic (endocrine) nature may determine what is called 
epileptic predisposition, i.e., the constitutional element of the disease. 
[Author's abstract.] 

Leriche, J. Pathologic Physiology of Jackson i an Epilepsy. [Presse 

med., September 15, 1920. J. A. M. A.] 

The author observed an attack of Jacksonian epilepsy while he was 
examining the brain. The sudden spasm of the cerebral arteries, induc- 
ing immediate and pronounced anemia of the cortex impressed him 
greatly. The C. S. F. he found diminished under pressure in the men with 
Jacksonian epilepsy following a war wound. The humeral artery on the 
side affected was also dilated in these cases, and its ligation had a favor- 
able influence on the peripheral sensations. These facts suggest that 
sympathectomy might favorably modify the circulation in the brain in 
cases of Jacksonian epilepsy. They suggest further the possible advan- 
tage of injection of small amounts of artificial serum, about 150 c.c. on 
alternate days, to maintain the proper pressure in the C. S. F. It is 
likewise possible that systematic ligation of the humeral artery might 
aid in warding off the attacks ; some of the men found out for them- 
selves that wearing a constricting band around the arm and tightening it 
when symptoms develop, would often abort the Jacksonian spasm. 

Braune. Trional in Epilepsy and Other Nervous Diseases. [Zen- 
tralbl. f. inn. Med., June 26, 1920. B. M. J.] 
Trional in doses of 0.5 gram twice daily is suitable for the treatment 
of epilepsy and is at least as valuable as the bromides. The danger of 
intoxication should not be disregarded, but can be avoided. The drug 
is contraindicated in patients with debilitating diseases. Regular action 
of the bowels and proper functioning of the kidneys must be maintained 



SENSORI-MOTOR NEUROLOGY 233 

and opportunities afforded for a long stay in the open air. Baths should 
be given several times a week and plenty of alkaline water ordered. 
Temporary interruption of trional treatment is necessary if larger doses 
than 0.5 gram twice daily are given. Bromides and other drugs can be 
combined with trional. Braune has found that trional diminishes the 
number and severity of the fits, shortens or prevents postepileptic stupor, 
makes the patient more peaceful, and improves the mental condition. 
Trional is also of value in increased irritability of the brain and nervous 
system. 

Pilcz, Alexander. Trional and the Treatment of Epilepsy. [Thera- 
peutische Halbmonatshefte, 1920, May 15, Vol. 34, No. 10, p. 291.] 
Braune calls attention anew to trional which as a remedy in epilepsy 
had been almost forgotten. The author believes that the reason this 
drug was abandoned was because of the dangers attaching to its use. 
He cites various authors who consider it harmful or even dangerous to 
life. Foreseeing that the good results attained by the new method of 
administering the drug may tempt physicians to use it, he emphasizes 
the warning that whenever trional is given for a period of from one to 
three weeks its use must be discontinued for the same length of time — a 
precaution which should never be neglected. [J.] 

Maillard, Gaston. Treatment of Epilepsy. Luminal. [L'Encephale, 

1920, July 10, Vol. 15, p. 455-1 

New treatments of epilepsy are received with skepticism by the pro- 
fession, and it was with little confidence that the author undertook his 
experiments with luminal when good results from this drug were re- 
ported by M. Raffegeau. The author was greatly surprised by the out- 
come of its usage, however. The effect upon the seizure itself as well 
as on the vertigo was decided and immediate. On the day following the 
administration of the drug the attacks ceased and did not reappear again 
at all, or only at long intervals. It seemed that the dose of luminal 
could be diminished to 10 or even 5 centigrammes per day and in these 
small doses prevent repetition of the attacks. The author gives graphs 
of 14 cases treated by him. In regard to the effect on the psychic dis- 
turbances, two series of phenomena must be considered, namely, the 
acute psychic disturbances and the chronic. The former seemed to be 
sometimes provoked at the beginning of the treatment with the drug. 
It seemed as though where the convulsive attacks were restrained the 
epilepsy becomes manifest in its psychic form. The author has never 
observed these acute psychic attacks except in patients who had pre- 
viously manifested psychic equivalents and here again luminal may be 
of aid, for the violent agitation may be averted by augmenting the dose 
for a couple of days when the first signs make their appearance. In the 
author's cases the psychic disturbances all finally disappeared, as did the 



234 CURRENT LITERATURE 

seizures and vertigo, under the influence of the continued treatment. 
The chronic psychic state is also marvellously influenced by luminal. 
[J-] 

Watkins, H. M. Epilepsy Treated with Luminal. [N. Y. Med. Jl., 

December 4, 1920. J. A. M. A.] 

Watkins states that cures are not to be expected from the use of 
luminal in epilepsy. It is at best a palliative remedy. It is not virtually 
a specific. It reduces the total number of convulsions in all classes 66 
per cent., although a small proportion of patients have an increased num- 
ber of convulsions during its use. It has practically no effect on some 
patients, and about 10 per cent, show untoward symptoms from its use. 
It has all the bad effects of bromides with the exception of the rash. 
The drug must be used over a long period of time and continually, as 
once its administration is discontinued the epileptic habit returns with 
increased severity. 

White, F. W. Appendicostomy and Cecostomy for Intestinal Stasis 

in Epilepsy. [Am. Jl. Med. Sci., August, 1920.] 

This paper deals with the results of appendicostomy or cecostomy 
with subsequent washing out of the large intestine for a period of six to 
twenty-six months in two patients with epileptic seizures and two are 
described as having " neurasthenia." The general theory was the auto- 
intoxication theory, but after the (psychogenic) factors had worn off 
the attacks were as bad as before. The author comes to a negative con- 
clusion regarding the validity of the hypothesis and the value of the pro- 
cedure, all of which has been abundantly shown over and over again. 
One neurasthenic patient was improved and one was not. In both epi- 
leptic cases the immediate results were fair. 

Marie, Orouzon and Bouttier. A Modified Borax Treatment of Epi- 
lepsy. [Presse med., October 9, 1920.] 

Experiments with borico-potassic tartrate are here reported upon. 
This double salt has been termed the "boric emetic," but this term is due 
to an error, for it possesses not a trace of such properties. In ordinary 
bromide medication the potassium salt has always been regarded as 
stronger than the other bromides, suggesting that the potassium compo- 
nent played some active role. Borax has had a limited use for many 
years. Tartaric acid does not seem to figure actively in the molecule 
but yields a double salt in which both boric acid and potassium are com- 
bined. In excessive doses the salt is a purgative. In testing a new 
remedy for epilepsy the reduction of the number of convulsive or minor 
seizures in a large number of epileptics is the criterion. The test is also 
made from the standpoint of the individual subject, since the treatment 
is apt to vary much with the personal equation. The only claim made by 



SENSORI-MOTOR X EURO LOGY 235 

the authors appears to be that the new salt is more efficacious than any 
of the older boric preparations and hence may develop some usefulness 
in bromide-intolerant patients. Further, by acting as a synergist, it may 
enable one to reduce the usual dose of bromides. In serial attacks and 
cases of status the authors have succeeded in reducing the number of 
daily convulsions, while in other cases the number of monthly attacks 
was cut in two; but the failures offset such results and show that the 
drug will hardly supplant bromides in the drugging of epileptics. 

Codet, H. Luminal in Treatment of Epilepsy. [Progres Medical, 

September 28, 1920.] 

The dose of luminal, phenol veronal, found most suitable were 0.3 
gm. per day for two attacks and then 0.2 gm.. returning to the larger 
dose if the seizures are not modified, and reducing the dose if there is 
too much sleepiness. The doses must always be fractioned. and this 
treatment should never be stopped abruptly. Hot baths are useful for 
excitement, and if the torpor is profound and the pulse weak, heat is a 
stimulant. The authors figures are on 16 epileptics. The report only 
indicates that the drug hinders the motor discharge. It does nothing to 
get at underlying causes. 

Labbe, M. Epilepsy and Diabetes. [Paris med., Mav 1. i<)2o. B. 

M.J.] 

The author here confines his attention to epilepsy occurring in the 
course of diabetes and gives an extremely superficial survey of this intri- 
cate problem. Epilepsy occurring in diabetic patients may be of various 
kinds — for example, there may be a coincidence of the two diseases, or 
a diabetic may have a fit, due to extrinsic causes, such as alcoholism, or 
uremia, or cerebral syphilis, tumor, abscess, softening, or meningitis. 
Four examples of epilepsy occurring in diabetes are given, to show that 
in cases of acidosis in which uremia and all other causes could be ex- 
cluded it appeared justifiable to attribute the epilepsy to acidosis. The 
attacks were observed during the stage of complete coma or in the pre- 
longed loss of consciousness. 

Laures, G., and Gascard, E. Urea in Spinal Fluid in Epilepsy. [Presse 

Medicale, June 16, 1920. J. A. M. A.] 

Six epileptics during epileptic seizures and during intervals, also six 
men with pronounced hysteria and two hystero-epileptics are here re- 
ported upon as regards the urea content of the C. S. F. The figures 
cited show that a marked rise in the urea content of the cerebrospinal 
fluid during an epileptic seizure, and a marked drop in the urea content 
in an attack of hvsteria. 



236 CURRENT LITERATURE 

Guillain, G. Diabetes and Epileptic Seizures. [Bull, de la Soc. Med. 

des Hop., June II, 1920. J. A. M. A.] 

Guillain reports a case of epileptic seizures developing for the first 
time in a soldier in the course of abute diabetes. The seizures subsided 
under treatment of the diabetic acidosis, and with them the left hemi- 
monitory stage ; they were localized or generalized, and followed by pro- 
plegia which had developed at the same time. In Labbe's four similar 
cases, the connection between the grave diabetic acidosis and the seizures 
was equally evident. 

Richter, Hugo. Is there a War Epilepsy? [Zeitschr. f. d. ges. Neurol. 

u. Psychiat., 1919, Vol. 46, p. 131.] 

By war experiences light has been thrown on the origination of both 
epilepsy and hysteria such as could not have been obtained by many 
years of observation under peace conditions. The author gives the re- 
sults of his experiences with epilepsy, covering a period of about eight 
months in the Garrison hospital at Budapest. He observed 450 cases, 
of which 250 developed epileptic seizures during war experiences. He 
gives extensive tables setting forth the causes in each case, the type of 
epilepsy, etc., and arrives at the conclusion that, in a considerable num- 
ber of cases where there are no considerable congenital stigmata or signs 
of degeneration epileptic seizures make their appearance following a war 
trauma (shock) and a permanent condition sets in resembling that ob- 
served in " genuine " epilepsy. In this sense the author states, it may 
be said that there is a war epilepsy, produced immediately and princi- 
pally by injuries and stresses of war. This view is entirely in con- 
formity with the theory advanced by Redlich concerning the nature of 
epilepsy. Those who succumb to war epilepsy are individuals in whom 
the tendency to epileptic reaction — a mechanism existing in every brain — 
is somewhat more easily set in activity than in persons exposed to the 
same experiences who do not develop the disease under the same strain, 
but less easily than in those who develop epilepsy even in the ordinary 
life of peace times. Even in these latter individuals congenital stigmata 
and sign of degeneration furnish indication of heightened tendency to 
epileptic reaction in only about one fourth of the cases. [J.] 

III. SYMBOLIC NEUROLOGY. 
1. PSYCHOLOGY — NEUROSES — PSYCHONEUROSES. 

Thurstone, L. L. Anticipatory Aspect of Consciousness. [Jl. Psy- 
chology and Scientific Method. 1919.] 

The fundamental thesis of this article is that every normal psychosis 
(mental state) is the expectation of experience, that it is forward look- 
ing and adaptive in function even when the mental state seems to be 
memorial or retrospective in character. The concept of the reflex cir- 



SYMBOLIC NEUROLOGY 237 

cuit is generally used with the simpler forms of action but we do not 
apply it as we could do in discussing larger psychological categories, 
including instincts and emotions. Every mental state can be thought of 
as the stage in an action. The simpler conative categories constitute a 
stage which may precipitate immediately into action, whereas the higher 
thought processes are earlier stages in the history of the act. Thus, a 
concept can be thought of functionally as an unfinished act which is 
conscious or explicit at an early stage before it becomes personal. The 
law of ideo-motor action applies to all of the psychological categories. 
Thus, a concept is an early stage in an adaptive act which tends to 
define itself toward overt completion. If it defines itself sufficiently to 
become personal it is more properly spoken of as an idea. The idea in 
turn defines itself into a still later stage of the act and finally precipi- 
tates into overt action unless inhibited. The article concerns only the 
categories which may be classified as belonging to the momentary psy- 
chosis, using the term psychosis as equivalent to a normal mental state. 
The same point of view can be extended quite readily to the permanent 
characteristics of the individual. In that case we have the concept of 
the reflex circuit, the tendency of this circuit to complete itself and 
define itself into overt action, as in interpretative principle on which to 
build our analysis of the permanent categories, such as instinct, the self, 
character, and motivation. I believe that the point of view here de- 
scribed will enable us to bridge the gap between discussions of the 
categories of the momentary psychosis in which psychology has primarily 
been concerned and the more permanent motives for action to which 
psychiatry has given so much attention. [Author's abstract.] 

Clark, L. Pierce. An Experimental Study in Mental Therapeutics. 

[Medical Record, Feb. 21, 1919.] 

The usual forms of occupational and amusement therapy, admirable 
as these remedies have proven, have only too often been followed in a 
stereotyped manner and made quite distasteful to the neurotic and psy- 
chotic. Our aim has been to seek several new and as yet not fully tried 
out remedies, and this rather unique therapeutic approach was applied 
to a heterogeneous group of nervous invalids during a trial period 
covering several months. The plan of therapy embraced four classes 
of school work: (1) Montessori and kindergarten classes for pupil pa- 
tients and pupil teachers, (2) out-of-door craftswork: woodcarving and 
cabinet making, (3) the teaching of English expression in reading, story- 
telling and dramatic work, and (4) rhythmic dancing. All the work 
was undertaken out of doors in groves and forests. The types from 
which the individuals were taken included psychoneurotics, retarded 
depressants, epileptics, organic palsies with slight physical and mental 
retardations, and speech disorders. The work was carried out under 
the supervision of experts in these four special fields who also possessed 



238 CURRENT LITERATURE 

insight into the nature of the mental defects treated and what was es- 
sentially needed for each patient. 

From the gratifying results obtained from this trial period I am 
convinced of the lasting value of such therapeutic remedies, and believe 
that rhythmic dancing, especially outdoors in natural surroundings and 
modified for men patients, has come to stay,. and should be more gen- 
erally employed. These new principles of mental therapy should be 
applied not only to mild nervous disorders in private practice but in 
sanatoria and modern public institutions. Not a little advantage is 
gained in making them very flexible in application and as an integral 
part of country life. Properly equipped such an experiment calls out 
the very best initiative of teachers, nurses and physicians. In our ex- 
perience there are many values in the novel and bizarre not obtainable 
in systems and routines haltingly or indifferently applied. So long as 
we train neurotics for normal life interests and the natural social activi- 
ties that grow out of them, we cannot go far amiss in mental therapeu- 
tics. [Author's abstract.] 

Ichok, G. The Tuberculous Psychoneurosis. [Zeit. f. Tuberkulose, 

February, 1920.] 

The author states that while well-marked psychoses following pul- 
monary tuberculosis are extremely rare, a psychoneurosis is often seen. 
Three forms of the disease may be distinguished according as it occurs 
(1) in cases with an hereditary history and in latent and abortive forms 
of pulmonary disease; (2) in chronic pulmonary tuberculosis; (3) in 
acute cases. This classification, however, must not be taken too rigidly, 
as a separation of the different forms is not always possible. Tuber- 
culous intoxication may not play the chief part in all cases, because, on 
the one hand, the psychoneurotic symptoms do not always increase with 
the progress of the pulmonary lesion, and, on the other hand, the char- 
acteristic picture may be fully developed with very slight lesions, or 
with merely a disposition to tuberculosis. It is suggested that the chief 
cause of the psychoneurosis is the consciousness of an organic inferiority. 

Amrein. Action of Tuberculosis on the Psyche and Character. 

[Corr.-Blatt. fur Schw. Aerzte, August 28, 1919.] 

The author devotes a long study to this subject without reference to 
the large literature. As a sanitarium phthisiologist he is evidently 
guided by his own finds but his paper is written with some reference to 
one on the same subject by Romisch in 1904. The psyche in this con- 
nection implies the inner existence and the character the outward ex- 
pression. Naturally the specialist in a long career sees all kinds from 
irresponsibles to heroes. The psyche and character of the child victim 
may be omitted in this connection although when the adult consumptive 



SYMBOLIC NEUROLOGY 230 

has suffered in childhood, tuberculosis as well, the early experiences 
must powerfully affect the mind in one way or another. Most con- 
sumptives are young adults or old adolescents whose characters have 
not had time for development. Other writers on the subject seem to 
have assumed tacitly that the victim has reached sufficiently mature 
years to show some responsibility. In such a case there must be a 
great conflict between the inclinations and the fate which seems to im- 
pend. The beneficent effects of work upon the character may not be 
realized if the subject is an invalid and under strict treatment. The 
victims are often young people of unusual talent and promise who are 
ambitious for themselves or others. Incapacitated for work they must 
think and speculate. They become introspective and upon the one sub- 
ject of their disease. They read popular articles about consumption 
and how to avoid and cure it. A singular fact even on the part of the 
scholarly is a form of the deterioration of taste. While at first one 
notes the taste for the classics these are in time replaced by stories of 
crime and its detection. The decline does not stop here for the next 
step is to read the frivolous and then to be indifferent to all literature. 
Even the newspapers pall. In other words the patient suffers from a 
progressive secondary neurasthenia which goes far to explain his men- 
tal make-up. He may even be classed as psychasthenic with his obses- 
sions of using the thermometer at all times and much behavior of the 
same type. If fairly able to get about he indulges in alcohol and flirta- 
tions and his motto seems to be carpe diem. Idleness is largely respon- 
sible for all moral delinquencies, plus the tendency to make the most of 
what remains of life. His behavior is not paradoxical but about what 
it would be under his peculiar circumstances. 



Book Reviews 



Tilney, Frederick, and Riley, Henry Alsop. The Form and 
Function of the Central Nervous System. [Paul B. 
Hoeber, New York.] 

This work is subtitled " An Introduction to the Study of Nervous 
Diseases." There are over a thousand large octavo pages divided 
into 50 chapters. Such an ambitious work calls for more than pass- 
ing attention and it deserves it, for it represents the most profound 
effort at a fundamental presentation of neurology that has appeared 
as a result of American neurological scholarship. 

No more lucid statement of the needs of medicine could be made 
than that found in the opening chapter on the importance and sig- 
nificance of the central nervous system, not only for students of 
neurology but for all observers of disease, bodily or social. Every 
phenomenon of human life is largely regulated by the nervous sys- 
tem. Heretofore students have had too much form and not enough 
function. Morphology has run ahead of physiology and the study of 
the nervous system has always been considered too difficult and too 
intricate to be worth while. The average man could make a living 
without it, so why bother? His general defence reaction has been 
to stigmatize the student of neuropsychiatry as " theoretical " and 
behind his self-complacent egotism conceal an ignorance so abysmal 
that it would be tragic if it were not so funny. 

That the authors here have seen the magnitude and seriousness 
of the crying need for intelligently trained doctors is evidenced by 
their considering this highly technical volume as an " introduction." 
It is this, but it is a thorough one, not an " introduction " in- the 
Quiz Compend sense that introduces no one to anybody, and only 
serves the false purpose of passing intellectual bluffs called exam- 
inations. 

Tilney and Riley first discuss the significance of the somatic 
nervous mechanisms which regulate the animal in his contact with 
the environment, and, secondly, the splanchnic or visceral mechanisms 
which have to do essentially with metabolism. The effort and the 
essence of life are their respective functions. The authors then take 
up the sensory and motor components in both the somatic and vis- 
ceral systems. These components they trace after first briefly out- 
lining what they do. 

All of life's manifestations are built up out of the compounding 
of the reflexes of these components. 

The authors then plunge into a series of embryological consider- 
ations. Notwithstanding the usual complexity of embryological de- 
scriptions these are singularly clear and are elucidated in an orderly 
manner. Superfluous material is omitted. Chapter IV deals with 

240 



BOOK REVIEWS 241 

types of nerve cells, neurones ; and their integration and chaining to- 
gether is dealt with in the following chapter. Three chapters on the 
general morphology of the spinal cord follow, and the histology and 
cell groupings in the cord, the relative arrangements of white and 
gray matter considered next. Here for a moment the authors hark 
back to old conceptions. When they say the control of the muscles 
[meaning voluntary, we presume] in all their complex activities is 
vested in the cells of the ventral gray column, we are quite sure 
they do not mean this literally. " This influence arises within the 
cell body itself and is independent of all other sources of nerve im- 
pulses within the nervous system." In an integrated mechanism can 
a single effector neuron be thought of as an independent source of 
energy? If as the authors have already held that the energy comes 
through receptors, how can it be a special isolated attribute of a cut 
off somatic neuron at its cell body end? This is the old-fashioned 
electric battery idea of a motor cell. In an energy system it still is 
only a transmitter not a manufacturer of energy. A few pages 
farther on [151] after being told that the motor cell is an independ- 
ent source of energy, we are told that the " motor-cells receive their 
impulses not alone from spinal cord dorsal root ganglia, but also 
from distant organs." Thus they are not independent sources. The 
concepts idiodynamic, intrasegmental, intersegmental, synergic, 
automatic associated and voluntary control are excellent and well 
illustrated. We feel a trifle discontented with the separation of 
function of white and gray matter. This is not an altogether logical 
mode of dealing with the dynamic conceptions these authors set out 
to elucidate. It is perhaps only a question of language, but we do 
not believe the separation as outlined is valid. Thus in chapter XI 
when they speak of the functions of the white matter in a cord seg- 
ment it seems to the reviewer to be distinctly misleading. The white 
matter of a cord segment is only part of a large connector system, 
the function strictly speaking is a part of the whole system. It may 
be disturbed at different points in the system. The place dis- 
turbed can lie said to have a function by itself only in a very limi- 
ted and limiting sense. Pathway function may be disturbed at dif- 
ferent parts with variable results, the variations in results may local- 
ize where the disturbance may be located : Is it good neurology to 
say that such variations as results are functions of the dislocated 
parts of the pathway? 

The authors distinctly avoid this difficulty when they later trace 
functional pathways as a whole. 

This type of elucidation is singularly well worked out in this 
volume. And the case history material is well integrated with the 
study of " functional relationships " of the region affected ; we pre- 
fer functional relationships " of areas involved to the " function " 
of this or that column. Such a concept would avoid an overschem- 
atization of cross section pathology which is here somewhat in evi- 
dence. Friedreich's ataxia for example. Nevertheless the method 
of rigid analysis of functional defects is to be highly commended. 

Chapter XIII begins the gross morphological study of the brain 
and its envelopes. The medulla is then taken up in six chapters. 



242 BOOK REVIEWS 

These are excellent, possibly the best in the volume for clearness of 
description and analysis of this difficult region. The reproduction 
of the micro-photographs of the histological structures, however, is 
much below what they should be. Analyses of pontine lesions then 
follow in two chapters, and cerebellar structures and functions in 
three. The chapters on the cerebellum are splendid. Three chap- 
ters on the mid-brain then follow. The analysis here of possible 
syndromy is fragmentary. Three chapters on the interbrain are 
quite full of embryological details and open up a large number of 
important questions. 

The following three hundred pages in fifteen chapters take up 
the endbrain. Surface anatomy, embryology, coverings, arterial sup- 
ply, cortical histology, projection and association systems, and nuclei 
are discussed seriatem. The various clinical syndromes are all too 
summarily taken up, but few are neglected, save perhaps the numer- 
ous cortical syndromics, and the more or less well established vascu- 
lar accident syndromes. An excellent glossary and a classified bibli- 
ography terminate this section. 

All in all the volume is one of splendid accomplishment and is 
a distinct contribution to neurological science. It is one of the most 
signally valuable products which has appeared from an American 
university and well merits the laudatory things said of it by Prof. 
Huntington in his appreciative foreword. It is an index of sound 
neurological scholarship, and a work of great value to all interested 
in neurology whether as morphologists or as clinicians. We wish 
it a well deserved success. Jelliffe. 

Kappers, C. U. Ariens. Die Vergleichende Anatomie des 
Nervensystems der Wirbelthiere und des Menchen, I 
Abschnitt. [De Erven F. Bohn, Harlem.] 

Neurological science has been waiting for a book like this. For 
the past 50 years students of the structure of the nervous system in 
all forms of animals have been investigating and recording their 
findings. Now and then a particular organ of the nervous system, 
the hypophysis, the cerebellum, the cranial nerve components, the 
lateral line organ, the frontal lobes, this or that sulcus or fissure, 
etc., etc., have been passed through the crucible of morphological re- 
search and been recorded in larger or smaller monographs of recog- 
nized value. But a clear, broad sweeping treatment of the general 
phyletic organization of the nervous system has been lacking. This 
is contained in the volumes which have come to us, the first portion 
of which on the invertebrates we have already mentioned. 

The animal body is conceived of in its most general capacity as 
an energy transmitter. Through the special receptor organs it re- 
ceives its stimuli that determine its conduct. The pathways by which 
such stimuli are organized for effector purposes in the steadily ad- 
vancing phyletic synthesis, which we call the nervous organs, are 
here most admirably traced. It is done in the best of scientific man- 
ners, neither too sketchily, nor yet too ponderously detailed. We 
believe Kappers has struck a most happy balance between a hasty 



BOOK REVIEWS 243 

generalized impressionism and a ponderous mountain of detailed and 
precise records which would need a lifetime to master. The essen- 
tial facts are there at the service of the clinician, and for use by the 
anatomist. 

The first fifty pages discuss the general morphology of nerve 
elements and in thirty more are outlined the general laws of con- 
nection of the neurones, the development of symapses and some 
fundamental concepts of reaction to stimuli and their consequent 
structural results. These Kappers has formulated under his law 
of neurobiota.ris an extremely suggestive and valuable general- 
ization in the study of the development of nerve organs, and which 
becomes an important principle in the interpretation of evolving 
structures in the nervous system. 

The second chapter deals with the comparative anatomy of the 
spinal cord. Amphioxus. Cyclostomes, Plagiostomes, Ganoids, 
Teleosts, Amphibia, Reptiles, Birds and Mammals are carefully com- 
pared and the successive organizations of the spinal cord, its sur- 
roundings and its protections developed. Illustrations are numerous 
and instructive, and further the concepts bearing upon the organ- 
ization and progressive developments of the spinal cord. 

In a third chapter the branchial system, the nerves of taste, the 
trigeminus and the components of the medulla are carried through 
the same animal series. In the fourth a similar discussion of the 
eighth nerve components, and the lateral line system of lower verte- 
brates is given. 

The effector systems of the medulla and midbrain follow in the 
fifth chapter, while the sixth and last takes up the coordinating path- 
way and synaptic junction systems between the medulla and the mid- 
brain. In this chapter the coordinating work of the olives is treated 
at great length. 

Each chapter has an extensive bibliography, so that further de- 
tails can be pursued by those eager to follow out any special line of 
investigation. 

With this general summary of the contents of this remarkable 
volume we leave it to our readers. No detailed analysis could serve 
any useful purpose. The book is a masterpiece not only evidencing 
the author's large grasp of the many intricate problems but above 
all it is a delightful exposition. We are enthusiastic about the book 
above the ordinary and believe that every worker in neuropsvchiatric 
fields who aspires to be well grounded in the structure of the ner- 
vous system should acquire it. Jelliffe. 

Hahn, G. v. Das Geschlechtsleben des Menschen. Johann 

Ambrosius Barth, Leipzig. 

This is a small thesis among the many dealing with problems of 
sexuality. They have been of all kinds, an index alike of the impor- 
tance and magnitude of the questions involved, as well as of prurient 
curiosity. This particular volume is quite similar to the general sex 
hygiene books which are familiar in all other tongues. It is a very 
pood one and is written for the lay public. 



244 BOOK REVIEWS 

Adler, Alfred. Die andere Seite. Leopold Heidrich, Wien. 

A short political polemic of socialistic trend regarding the recent 
war. It is termed an essay in mass psychology. 

Federn, Paul. Zur Psychologie der Revolution. Anzengruber 

Verlag, Wien. 

An interesting psychological interpretation of a fatherless society, 
as descriptive of the revolution in Austria and Germany and other 
continental countries, based upon certain aspects of the Freudian 
psychology. Society has lost its old type of father, the King, and 
seeks to replace it by a substitute. He very clearly shows how long 
a process it must be before the state builds for itself a really pro- 
gressive father substitute. Present-day society being governed so 
fundamentally on nationalistic ego tendencies, hating all encroach- 
ments and murdering its neighbors still on the pattern of the family 
rivalry so productive in making individual neuroses. 

Brown, W. Langdon. The Sympathetic Nervous System in 
Disease. Oxford University Press, London and New York. 
A very valuable short resume of vegetative nervous pathology — 
not as complete as Higier's valuable monograph, nor as some recent 
works in neurology, yet to be read and kept for reference. It con- 
tains the fundamental concepts which an advancing neurology must 
utilize. 

de Jong, Herman. Die Hauptgesetze einiger wichtigen kor- 

PERLICHEN ERCHEINUNGEN BEIM PSYCHISCHEN GeSCHEHEN VON 

Normalen und Geisteskranken. Julius Springer, Berlin. 

This doctorate thesis from the Amsterdam faculty is an interesting 
and important contribution toward the problem of determining values 
concerning states of tension in the vascular mechanism in healthy and 
sick individuals, particularly as applied to the problems of psychiatry. 
The plethysmographic study of vascular variations arising on a basis 
of emotional states is the chief interest of the paper. Vascular 
spastic states as observed in catatonics are well illustrated. The whole 
problem is well brought out, although to the reviewer the general 
subject of vascular tonus can not be used to solve the particular prob- 
lems. They are too individual. Individual vascular alterations that 
accompany action pattern integrations must be valuated, nevertheless 
de Jong has made a good beginning. 

Quercy, Pierre. £tude sur i/Appareil Vestibulaire. Imprimerie 

Regionale, Toulouse. 

The vestibular apparatus is the most constant of the cranial sen- 
sory organs of vertebrates. There are blind vertebrates, there are 
anosmic vertebrates, entire orders are deaf, and the lateral line organ 
belongs only to certain vertebrates leading an aquatic life. The nerve 
of space, however, is practically never missing. It is primitive in 
some and anomalous in a few pathological instances, as the Japanese 






BOOK REVIEWS 245 

dancing mice, but absent never. The author therefore devotes a book 
of 200 pages to tracing its phylogeny, to describing its mammalian 
structures and to outlining a few characteristic syndromes due to 
disease implicating its structures. 

This he does in a very acceptable manner and has given us a read- 
able and valuable thesis of this nerve of space, regulator of tonus, 
of static sensibility, of time relations, and of proprioceptive integra- 
tive activities. We believe him incorrect in speaking of its diminish- 
ing importance in the advancing animal phylum and to have analyzed 
very imperfectly the advancing evolution of the cochlea as an integral 
part of the entire vestibular mechanism. His failure to grasp the 
gradual development of space regulation through the speech and hear- 
ing mechanism — symbol activities in the human being — leaves a lacuna 
in his work of transcendent importance. The purely sensori-motor 
functions are well grasped, but the vegetative and symbolic integra- 
tions in this important instrument are not at all sensed. Winkler's 
new study of the eighth nerve in his Manual of Neurology gives us 
this new note in the evolution of symbolic function which Quercys 
work does not attempt. 

Tilney, F., and Howe, H. S. Epidemic Encephalitis. Paul B. 
Hoeber. 

This is a most excellent even if sketchy account of the protean 
manifestations of epidemic encephalitis. The authors speak of it as 
a specific entity and divide their case material of twenty cases into 
nine groups. Short case histories are given with autopsy findings in 
a few. Discussion of the pathological findings is full and well illus- 
trated, a reprint from the author's article in the Neurological Bul- 
letin. In the concluding chapter the authors regard the disease as 
a specific one. Fourteen types are recognizable, the cause is as 
yet unknown. On the whole this little book offers a quick orientation 
toward an extremely important subject. 

Sergent, E., Rihadeau-Dumas, and L. Babonneix. Traite de 

Pathologie Mentale. VIII. Psychiatrie. Tome II. A. 

Maloine et Fils, Paris. 

We have had occasion to refer to the first volume of this section 
of a recent Traite de Medicine on Psychiatrie. Vol. II consists of 
eight chapters. Colin and Demay write upon Insane Criminals ; Le- 
grain, upon Infectious and Topic Psychoses; Barbe upon Degenera- 
tion ; Deny on Dementia Praecox ; Truelle on Organic and Senile 
Dementia ; Brissot on Aphasia ; Bonhomme and Padet on Paresis ; 
Charon on Legal forms of Internement ; and Vallon on Jurispru- 
dence. 

We can only reiterate what has been said in the discussion of the 
first volume. We find nothing new — nothing illuminating. Barbe's 
chapter on Degeneration, which is the largest, repeats the fruitless 
French generalization of Degeneration which means practically 
nothing save an evasion of careful clinical study. In it everything 



246 BOOK REVIEWS 

is thrown which meets with disapproval of a purely absolutistic 
idealism of what should be called normal. It contains much inter- 
esting material, but thrown together in a huge grab bag of idiocy, 
imbecility, mental debility, episodic syndromes and polymorphous 
delirious manifestations. _ 

Deny's chapter on Dementia Praecox is a sincere attempt at a 
description of this vast syndromy but it offers no real advance on 
conceptions already well known and here quite superficially ap- 
praised. 

The medicolegal chapters, pertaining as they do to Fniench 
jurisprudence, contain no pertinent material for English readers. 

Oertel, Horst. General Pathology. Paul Hoeber, New York. 
$5.00. 

To the neurologist general principles of pathology should be of 
transcendent importance. The neurologist, with wide open eyes, 
views pathology as a dynamic process, correlated by the activities of 
the vegetative nervous system. Regretfully no such attitude of 
mind is found in this volume. It is therefore of value to the neu- 
rologist only in a secondary sense. It throws no particular light 
on his problems, excellent though it be for students of the narrower 
realms of pathological processes from a purely descriptive stand- 
point. 

Clarke, R. H., and Henderson, E. E. Investigation of the Cen- 
tral Nervous System. Atlas of Photographs of Frontal 
Sections of the Cranium and Brain of the Rhesus Mon- 
key. Johns Hopkins Hospital Reports. Special Volume. 
Baltimore. 

Two sections are here combined. First, a description of the 
Horsley stereotoxic instrument for accurate localization of extra 
cerebral and intracerebral correlations, as applicable in surgical 
technic, and secondly a series of photographs of serial section of the 
brain of the rhesus monkey originally started as a continuation of 
related cat sections from the Vogt laboratory and published here 
rather than in the Journal fur Psychologie und Neurologie as a re- 
sult of recent international complications. 

Their interest to the neurologist is purely as references. 

Stowell, W. L. Sex for Parents and Teachers. The Macmillan 

Company, New York. 

Of late years there has been a plethora of books upon sex. As 
Stanley Hall says in his introduction to his volume, many have been 
pernicious. This cannot be said of this very simple discussion of the 
fundamentals which underly the development of human beings and 
the ways by which human societies are built up. In all its simplicity, 
which is admirable, there is, however, one note lacking, namely, the 
great complexities which have come to be organized in this the 
most complex and intricate of all human mechanisms. For the be- 



BOOK REVIEWS 247 

ginner, however, this work can be most heartily commended. May 
it form one of the links of a chain which will free mankind from 
his false modesty which is so largely capitalized and made the sport 
of demagogues and charlatans the world over. 

Freud, Sigmund. Die Traumdeutung. Franz Deuticke. Wien. 

1921. M.50. 

A sixth edition of Freud's interpretation of dreams follows 
upon his fifth which appeared in 1918. To all interested in the ad- 
vances made in the intense psychoanalytic work which has been 
stimulated by Freud's researches this new edition should be welcome. 
Although it appears more or less the same as the edition of 1918 — 
which edition, by reason of war transportation difficulties, was 
available to few outside Germany, there are a number of valuable 
additions which make it indispensable to workers in psychoanalysis, 
and of value to the general reader. The entire literature since 
1900 — the date of the first edition — has been collected by Rank, 
and furthermore this same research worker has added a series of ad- 
ditional studies to Freud's original volume. These are of much 
originality and value. 

Cotton, Henry A. The Defective Delinquent and Insane. 
The Relation of Focal Infections to their Causation, 
Treatment and Prevention. [Princeton University Press, 
Princeton, N. J., $3.00.] 

Cotton has here presented a very readable and constructive 
volume. He has accented a crying need in all of our institutional 
work — namely, aggressive therapy. He has applied this along lines 
which, to some seem exaggerated — what is not so considered by 
some others — to the end that many patients have been benefited. 

Systemic infections undoubtedly may play a role in psychotic 
states — possibly such play an infinitely greater role for some than 
for others, for every individual is conditioned differently to different 
stimuli, whether such be atmospheric pressures, toxic substances, or 
social environments. One man's meat is another's poison, and an all- 
around vision of mental disorders must take into account, not only 
the personality makeup that enters into the struggle for personal and 
phyletic existence, but also of the possible environmental deterrants 
that may make the struggle ineffectual for this or that personality. 
It may be a great oversight to lay too much stress upon any narrow 
series of factors, but it certainly is an even greater evil to neglect 
everything and treat hospital patients simply from the boarding 
house economic point of view. 

Toxic agents are among the obvious detrimental environmental 
factors. Remedy them at least, says Cotton, and with this we are in 
hearty accord. They may be the last straw that breaks the camel's 
back. We do not, with the author, believe they are as heavy burdens 
as he outlines — but no one can say how heavy they are unless they 
are at least removed as far as possible. Only a determination to get 



248 BOOK REVIEWS 

rid of them can develop any true judgment — and the proof of the 
pudding is the eating. That a judicious appraisal of the whole situ- 
ation is necessary, we believe, and the author is to be commended for 
his courage in going after things, which primary or secondary, never- 
theless enter into a vicious circle of cause and effect, to the de- 
struction of human beings. 

Buckley, Albert C. The Basis of Psychiatry : A Guide to the 
Study of Mental Processes. [J. B. Lippincott. Philadelphia 
and London.] 

The author in his preface makes an admirable appeal. He offers 
us a vision towards which psychiatry has been straining for a num- 
ber of years, that fundamentally, as Maudsley, Mercier, Kraepelin. 
Freud, White, Meyer and others have insisted, each with their 
own terminologies, the problems of psychiatry, for the most part are 
those of behavioristic reaction, chiefly to social environmental fac- 
tors. Sociotropisms they might be considered, and therefore are 
best studied as general biological reactions, in which that which has 
been so sharply differentiated by former generations as mind, is 
only a manifestation of these biological activities and can not be 
comprehended as something separate and distinct, as the faculty 
psychology attempted. 

This favorable impression is carried through into the author's 
first historical introductory chapter, although this can hardly be said 
to deal with anything like an historical introduction into the develop- 
ment of psychiatry per se. It is only a statement that psychiatry is 
now, sometimes, regarded as a branch of medicine. Should the 
author look up our college curricula it would appear that it hardly 
has been admitted into medicine save here and there — but it is 
coming. 

Chapter 2 deals with biological phenomena which an educated 
medical student should have obtained somewhere else, — so also the 
anatomical details of cerebral development and receptive organs. The 
bibliographies, as alternative reading are valuable but not discrimi- 
native enough. Chapters 4 and 5 deal with psychological factors. 
They are quite satisfactory, but still a trifle academic. We have 
come now to one quarter of the book. The author then takes up 
the subject of etiology. This too is very interesting, many opinions 
are expressed, but they are thrown more or less helter-skelter, more 
suggestive of the efforts of a clipping bureau rather than those of a 
carefully worked out discussion. When the author speaks of a lack 
of knowledge of mental diseases among civilized races, he is unin- 
formed. Comparative psychiatry, though a young, is nevertheless a 
lusty child, and there are a large number of extremely interesting 
observations; Kraepelin's on the psychoses in Java, Brill on the 
Eskimo, to instance but two of the many studies. 

Chapter 8 deals with Classification. The author reproduces that 
of the American Psychiatric Association of 1917. We are pleased 
to note the omission of the word insanity in this well presented chap- 
ter. Symptomatology, and Methods of Examination then follow. 



BOOK REVIEWS 249 

These two might advantageously have been combined and the de- 
tails 'of the Wassermann and other laboratory tests omitted, with a 
^discussion of their significance inserted, such as are found later in 
paragraphs, as for instance, on the toxic-infection psychoses, p. 223. 

These occupy one-half of the book. Part II, that now follows, 
discusses the psychoses in general following the A. P. A. scheme of 
classification. Here one looks in vain for any elucidation of the out- 
lined scheme of reaching for a psychobiological formulation as an 
aid to the understanding of the mental reactions. As an example, 
one is told that " dipsomania is an extreme morbid craving for alco- 
hol." Can a craving for alcohol have been integrated into the bio- 
logical structures? We suspect not. The real craving is to get to 
a type of consciousness, in some way ; the alcohol is simply the 
medium. One might go on to cite a number of similar survivals of 
the old psychiatry and indeed one searches in vain for the carrying 
out of the promise of the preface. It not only is not fulfilled, but 
apparently has been a quite forgotten, even if eloquent, gesture. Only 
in the chapter on the schizophrenias is a. brief reference made to the 
subject. 

We had hoped for a real radical rearrangement of the psychotic 
mosaics on psychobiological principles, such an one, as for instance 
Kempf has so ably sketched, but unfortunately only the old descrip- 
tive psychiatry of the Kraepelian or pre-Kraepelian period is offered 
us, and that none too connectedly. Albeit, the book is not by any 
means a negligable one, even if the promises were over ambitious. 

Alexander, Hartley Burr. Latin- American. Vol. XI. The 
Mythology of All Races, fin Thirteen Volumes. Louis 
Herbert Gray, Editor; George Foot Moore. Consulting Editor. 
Marshall Jones Company, Boston, 1920.] 

No one of this series of books devoted to mythology is better 
fitted to give genuine pleasure to the student or the general reader. 
The qualities which distinguish it even among the other excellent 
volumes of the series arise both from the author's equipment and 
from the range of his subject. The sustained literary excellence, 
his broad grasp of the genuine human interests here represented are 
devoted to the presentation of the mythology of a people who have 
a rich past to be explored. The author explains the choosing of a 
name for this study so inadequate to the comprehensive geographi- 
cal as well as anthropological conception which he has of the peoples 
of America. Yet the name is not without significance if only for 
the reason that the Latin people, the Spanish themselves added more 
than a color to surviving myths. At the same time the background 
is one not only of a striking primitive lore, but also one of peculiar 
wealth of development in art, religion, political life. For there is a 
wide range of culture among these peoples reaching literally from 
pole to pole on the American continent. The writer recognizes the 
great distances which separated them geographically and in the dif- 
ferent layers of development they had attained. Yet with this he 
recognizes a " racial complexion of mind ... a kinship of the spirit- 
ual life " which gives a unifying appreciation to a study of the 



250 BOOK REVIEWS 

northern American peoples (Vol. X.) The exceedingly valuable 
plates which abound throughout the book give evidence of the' rich 
field mythologically and historically to which this book is devoted. 

Hall, G. Stanley. Recreations of a Psychologist. [D. Apple- 
ton and Company, New York and London. 1920.] 
One feels in this book the rich background of one who has spent 
many years in the accumulation of psychological knowledge and the 
development of psychological theory. Not only are psychic prob- 
lems or psychic facts of various sorts admitted in the character 
sketches and descriptions of events which are here given. There is 
besides that broad sympathy of the author which enables him to view 
life in this deeper underplay of psychic factors as well as in its the 
superficial aspects which first catch the attention. One could wish 
that he had been less vaguely suggestive in regard to these deeper 
psychic questions and spoken with more of the distinctness which 
has been found so convincing in his more strictly professional work. 
The longer chapter upon " The T^all of Atlantis " is a study of 
social evolution and degeneration of a fancied civilization. Its op- 
portunities are similar to ours, the causes of its degeneration are 
those factors which can be seen at work to-day so that the story 
carries an intended warning. It gives food for thought though we 
may not find even here, the drawing of the picture as convincingly 
direct as one could wish. 

Ferenczi, Dr. S. Hysterie und Pathoneurosen. [Internation 
aler Psychoanalytischer Verlag, Leipzig and Vienna.] 
Ferenczi is one of those writers whose words are concise and gi 
straight to their point. He understands psychoanalysis so thorough- 
ly that he brings it directly to bear upon the difficulties that come 
before him or upon the matters which he discusses. There is pre- 
sented here a collection of studies, based upon practical experience, 
in regard to various phases of hysterical manifestation and other 
problems which come before the psychoanalyst. He presents a sug- 
gestive paper upon the creation of a narcissistic neurosis by the 
psychic trauma resulting from injury of any part of the body when 
there is already constitutional overvaluation of the self, when the 
injury threatens the existence of the ego or when it concerns a part 
of the body specially toned with libido. His brief report of his oc- 
cupation with war neurones is richly illustrative of the psychic dis- 
turbance to be sought behind the apparently physical symptoms. 
Even a superficial analysis reveals these and finds that they con- 
stitute an anxiety or a conversion hysteria in which the symptoms 
prove to have definite meaning. 

Katz, Leo. Marga Rother. Dramatisch-psychologische 
Studie in drei Aufzugen. [Von Atlantik- Verlag, Berlin W. 
1920. Pp. 54.] 

Psychoanalysis makes us for a time self conscious of much that 
was once unconscious. The dramatist has frequently revealed this 



BOOK REVIEWS 251 

in the attempt to utilize those unconscious factors which, only re- 
cently become known, have not yet found a sufficiently accus- 
tomed place in consciousness. Such a dramatist's psychoanalytic 
knowledge is clumsily applied. It is not so with this drama. One. 
cannot know whether the author is making such an application or 
only intuitively bringing to light unconscious complexes. What he 
does is done deftly. He touches with truth the sister's absorbing 
love for the brother, its terrific power to dominate her life even to 
the point of a crime permitted by the overthrow of reason. He 
shows how such fixation is related to her withdrawal from the 
world, her attempt to find the unconscious wish in religion, to absorb 
it in music. The drama is too simply true to human reality to offend 
in its pathology. One feels the coming tragedy through the tin- 
healthiness of the sister's love. Yet although the form of the tragic 
end is not suspected. It is in the very naturalness of human setting 
that the curtain is lifted to reveal these deeper factors which destroy 
life. 

Pfister, Dr. Oskar. Wahrheit und Schonheit in der Psych- 
analyse. [Rascher & Cie. Verlag, Zurich.] 
Pfister makes no effort through this work to force truth and 
beauty upon psychoanalysis for its justification. The title might sug- 
gest this did the writing not come from one well known for the sin- 
cerity of his writing as well as his profound appreciation of the reali- 
ties of life and their interrelation. In this brief study he has again 
presented these as the objects, the facts upon which the work of 
psychoanalysis is directed, for the discovery and understanding of 
which it stands as a science. Therefore the truth and beauty of 
which he speaks in relation to psychoanalysis are those that lie in 
facts. Facts are inescapable at least for the scientist who is in 
earnest. It may be that in their uncovering, ugly phases must ap- 
pear. They must even be dealt with. Yet if the reason therefor be 
that of a readjustment in the interests of esthetic comprehension of 
life, intellectual clearness and ethical mastery of life's instinctive 
forces then the goal is that of beauty in the truest sense. It lies in 
the whole of truth. Beauty thus comprehended finds its attainment 
in that fuller truth shown to be the goal of psychoanalysis. The 
book contains in its small compass much richness of material in clear 
< xposition. 

Hoch, A. Benign Stupor, A Study of a New Manic Depressive 
Reaction Type. [The Macmillan Co., New York, 1921. 284 p. 
Price $2.50.] 

This little book comes to the many who counted Dr. Hoch among 
their friends as a pleasant surprise, a sort of renewal of a valued 
association. It is a clinical study in Dr. Hoch's best style, an analysis 
of the benign stupors, and an attempt to define their characteristics, 
to differentiate them from the malignant reactions of similar character 
and to explain their mechanisms and their symptoms in detail. It 
was characteristic of Dr. Hoch that he kept close to his case material 



252 BOOK REVIEWS 

and this study is no exception to that rule. It is a closely analytical 
study of actual cases and represents American clinical psychiatry at 
its best. It is a distinct and original contribution of great value, full 
of stimulating suggestions and interpretative hypotheses and free 
from the restrictions incident on attempting to force cases into some 
accepted nosological group. Dr. Hoch was singularly free from the 
domination of systems of classification and was able therefore to con- 
sider each patient as an individual problem, free and untrammeled by 
the prejudice of having to apply a conventional label. 

The book is made up of material which was gathered from Dr. 
Hoch's notes after his death by Dr. MacCurdy. Dr. MacCurdy's 
work has been most admirably done and any hiatuses in the notes 
which may have occurred are not apparent to the reader. He is to 
be congratulated for a good job well done. 

And finally, the book emphasizes again the serious loss to 
American Psychiatry by Dr. Hoch's death. Had he lived we might 
have all benefited by a number of such illuminating studies, as it 
was Dr. Hoch's intention to devote his time largely to the careful 
study of the rich case material which he collected during his clinical 
experience. White. 

Janet, Pierre. Les Medications Psychologiques. Etudes His- 

TORIQUES, PSYCHLOGIQUES ET CLINIQUES SUR LES METHODS DE 

la Psychotherapie. [Felix Alcan, Paris.] 

This three volume treatise is most entertaining and profitable, 
albeit there are many, too many words. They contain an excellent 
digest of current winds of psychotherapeutic doctrine. In most in- 
stances the author has made, to us, a satisfactory and reasonable 
estimate of the forces at work in this most important field of medi- 
cine. In some Janet has completely failed to entertain useful hy- 
potheses or to outline correctly well known principles. His ignorance 
of the Indo-Germanic tongues makes him strangely oblivious to most 
excellent work in psychopathology which has been progressing in 
Austria, in Germany, Holland, Norway and Sweden. When he has 
called attention to these it is obvious that his information con- 
cerning them has been obtained from second-hand and quite inade- 
quate sources. Thus his idea of the use of Jung's association experi- 
ments is quite nonsensical, and his survey of the psychoanalytic 
movement absurd if not maliciously maladroit. 

Perhaps it is too much to ask that a work published in 1919 but 
which consists of a series of re-edited lectures dating from the 
year 1904 should contain matters of psychopathological importance 
up to date. At any rate they are not, although they are most read- 
able and are an excellent example of Janet's quite extraordinary skill 
in presentation. Because of his grace of expression much can be 
overlooked in the way of erudition or scientific curiosity. 



BOOK REVIEWS 253 

Henschen, Salomon Eberhard. Ueber Aphasie, Amusie und 

Akalkulie. Ueber Sensorische Aphasie, V & VI Teil. 

[Nordiska Bokhandeln, Stockholm.] 

Henschen here contributes two more quarto fascicles to his 
previous researches on the Pathologie des Gehirns. 

We should like to give to these two works the space their merit 
deserves but this is impossible in view of the avalanche of new 
works which should be brought to our readers' attention. 

Henschen, as is well known, belongs to the anatomical school, 
as contrasted to those who believe, like Head for instance, that the 
aphasia problem is primarily a psychological one. Basing his studies 
on the cytotectonic of Brodmann and other students of cortical 
topography Henschen would apply these ideas to the study of the 
various aphasias. He traces the aphasie localizations up from ges- 
ture localizations applying Wundt's ideas concerning the origin of 
language. Word blindness and word deafness have quite different 
cortical areas, the former being associated with lesions of the left 
angular gyrus, the latter related to lesions of the posterior two-thirds 
of the first left temporal convolution. 

We can not here trace out the many, details arising from the 
author's masterly review of all of the known case histories, which 
although at times rather scantily abstracted, yet nevertheless present 
an imposing array of evidence. 

The whole study is most fascinating, especially the author's dis- 
cussion of educability of the right hemispheres and the part they 
could be made to play in the general intellectual synthesis. They 
are an almost uncultivated field and can be much more zealously used 
for the preservation of racial experience. 

Hall, H. C. La Degenerescence Hepato-Lenticulaire, Ma- 
ladie de Wilson. Pseudo-sclerose. [Masson et Cie, Paris.] 
This delightful monograph of 350 pages on various types of 
lenticular-liver degeneration, with a graceful introduction by Pierre 
Marie, comes as a welcome summary of our knowledge concerning 
this important and interesting group of syndromes. 

Hall has collected the case histories of about 68 cases with at 
least 23 autopsies, 16 of which are quite detailed. Of these 3 are 
from his own hospital service in Denmark. 

He begins his study with a short resume of Wilson's descrip- 
tions in Brain and also an analysis of the same author's important 
monograph in the Lewandowsky, Handbuch. Chapter II deals with 
the historical evolution of Wilson's disease and that of the pseudo- 
sclerosis of Westphal and Strumpell. Personal observations on 
seven cases constitute the next chapter which is followed by a 
synoptic table of the cases of Wilson's disease and of pseudosclerosis 
published since 1912. The symptomatology is next considered in 
great detail. Chapter VI deals with the pathological anatomy. This 
is a most valuable chapter. The next on the corneal pigment brings a 
number of new observations within the clinical picture. 



254 BOOK REVIEWS 

Chapter VII takes up the relation of Wilson's disease to Ziehen's 
torsion spasm. Thomalla's dystonia lenticular synthesis does not 
entirely satisfy him and in his next chapter the whole group of 
striatum syndromes is most intelligently discussed. Hunt's work is 
known and appreciated by the author. 

The complexity of the whole situation is most adequately set 
forth by the author. He is inclined to separate out a distinct familial 
group which includes both Wilson's disease and many pseudosclerosis 
cases in which heredity is conceived to play the chief causative role. 
This type is to be considered a congenital constitutional anomaly, an 
abiatrophy, in which the hypothesis is advanced that the disease is 
produced by the union of two genes, one of which is spread in a 
general manner in the population of the locality and transmitted by 
dominance or by recessive heredity, the other is of specific family 
importance and is a Mendelian dominant factor. The mesencephalic 
and liver factors are considered as parallel processes, both of which 
are due to congenital debility of these organs. 

The monograph is well worth reading. The reviewer feels that 
the author has not laid enough stress upon the idea that there may 
be a closer relationship between the striatal pathology and a trophic 
reaction in the liver, viewed from the standpoint that important 
synaptic integrations of upper vegetative neurons have been inter- 
fered with. This would afford a more monistic view of the whole 
group, but considering the as yet sparse collection of data regarding 
upper vegetative pathways it is perhaps safer to stick to the older 
orthodox heredity schemes of interpretation, even if they do not ex- 
plain anything. 

Long, Constance E. Collected Papers on the Psychology of 
Phantasy. [New York, Moffat, Yard and Co. 1921.] 
The writer of this book has a broad grasp of the fundamental 
principles of analytical psychology. She knows how to bring them to 
a variety of readers in a direct form which makes them applicable 
to a variety of practical needs. The book in its appeal to the educator 
or other social worker as well as to the medical student of these 
principles of the psychology of the unconscious is simple, readable, 
forceful. Dr. Long speaks from her own wide range of interest and 
from her own medical experience as she watches this psychology 
taking hold of the difficulties in human lives. 

She has conceded the term analytical psychology for she frankly 
stands for Jung's particular development of the psychology of the 
unconscious rather than that of Freud. She is however acquainted 
with the basic discoveries upon which all of the branchings of the 
original psychanalytic theory rest and freely acknowledges the in- 
debtedness for these to the genius of Freud's research. She makes 
an acknowledged effort constantly to give due credit to freud and 
point out his specific contributions in this application of the psy- 
chology of the unconscious. She also takes pains to state the leading 
principles of Jung's line of thought so that the comparison gives the 
book a special interest as it comes from the pen of one whose work 



BOOK REVIEWS 255 

proves that practice and theory are united. She is less clear however 
in this setting forth of Jung's position than in the application of the 
psychology to practical questions. Is it only a Freudian prejudice 
that makes one see more clearly through her writing just where the 
fundamental difficulty lies which has caused the deviation? This 
difficulty serves to make Freud's fundamental position incompre- 
hensible to Jung and his disciples and it sends them into somewhat 
metaphysical flights of thought. The extreme simplicity of Freud's 
initial conception is that the whole psychic life, call it libido or what 
one will, is included in two fundamental instincts which start out in 
extremely close relationship and out of which all else arises. Failing 
to grasp this, these critics do not see why sex prevades all expression 
and why analysis must always discover sex at the root of all mani- 
festations. This simple fundamental statement of Freud obviates 
the confusion that arises from the attempt to explain other groups 
of impulses by the side of the reproductive instead of within it. 
The use in the book of both the terms, subconscious and unconscious, 
also does not tend to clearness of understanding. 

Bayliss, W. M. Principles of General Physiology [Long- 
mans's Green & Co., London and New York. $9.50.] 
It is but a short time since we reviewed an earlier edition of this 
really remarkable book; a book which we repeat is almost an ab- 
solute necessity for any worker in neuropsychiatry at the present 
time. No one has so adequately discussed the trends that modern 
studies in physiology are taking us — particularly in the increasing 
necessity for following out the neurological processes within the 
body. Although even Bayliss himself has not quite adequately 
stressed the full significance of the organism as a whole, made so 
by the masterly organization effected by means of and through 
neural structures, by which it captures, transforms and delivers 
energy for the preservation of the individual, and even more im- 
portant, for the continuance of the phylum, even if this larger view 
point is not always in mind, yet the general attitude comes much 
closer to it than any contemporary work. 

We welcome this new edition, although we should like to see an 
entire revision of the vegetative or visceral nervous system, especi- 
ally showing its automatic activity in relation to the older phyletic 
metabolic integration. When Bayliss, following Langley and many 
others, speaks of the vegetative system as an outflow from the sen- 
sori-motor system we think him distinctly wrong. It is not in the 
Pori ferae or Coelenterates. It is a primary system; the sensori- 
motor system is the secondary one. This is a distinct lack in the 
book for the neurologist. A number of minor subjects might be 
taken up — thus Bloch's interesting researches on the skin pigments 
as light receptor mechanisms, the relation of this pigment to adrena- 
lin, and the whole problem of sympathetic upkeep through the 
external stimuli as well as through the chemical sources of energy. 
We would also like to see a more progressive attitude towards the 
whole energy transformation possibilities in other terms than carbon 



256 BOOK REVIEWS 

and oxygen. If Sir Oliver Lodge is correct when he says that 
millions of foot pounds of energy are locked up in a common crayon, 
certainly calcium plays some part in the energy formulae of the 
human body, and why not sodium, or potassium, and iron and all of 
the 26 integrated chemical elements. What are they there for? 
Certainly they are not museum pieces for biological chemists to 
look at. 

In a new edition we would like to see a better discussion of the 
relationships of tonus, the proprioceptive system, the labyrinth and 
the mechanism of sound and voice- — for the correct appreciation of 
which the Dutch physiologists and neurologists have led the way. 
The work of Kappers and the significance of neurobiotaxis certainly 
should be incorporated and the masterly studies by Winkler, Magnus, 
deKleyn, and the Dutch school on the 8th nerve in its relations to 
space orientation and the projicient apparatus acting through the 
sound receptors and developed to integrate through the symbol. 

Jelliffe. 

Abraham, Dr. Karl. Klinische Beitrage zur Psychoanalyse. 

[ International Psychoanalvtis'cher Verlag, Leipzig, Vienna, 

Zurich. 1921.] 

This collection of papers fulfills its purpose in a particularly 
happy manner. Abraham has collected out of an experience of four- 
teen years material which brings forward and illustrates many 
questions which arise before the psychoanalyst. These may occur as 
one considers the applicability of psychoanalysis to any number of 
current problems or they may be those which have a specially acute 
bearing upon some matters arising in actual daily work with patients. 
Here in fact the author has faced the problems he treats. In either 
case the psychoanalyst will find here treatment of a wide range of 
such subjects and given in a manner brief, clear, straight to the 
point. The collection of papers is one that can be picked up for a 
moment's helpful reading or for a more prolonged study into the 
matters and methods of psychoanalysis. 

Pfister, Oskar. Zum Kampf um die Psychoanalyse. Inter- 
nationaler Psychoanalytischer Verlag, Leipzig, Vienna, Zurich. 
Pfister writes of psychoanalysis not merely with a knowledge of 
its principles theoretically acquired but because he has had successful 
experience with it in the fruitful field of work with the adolescent 
as well as with other individuals. He is also well fitted to make the 
comparisons to which he has here given careful attention as he points 
out the relation of psychoanalysis to other fields of thought and 
endeavor. He appreciatively reveals the common meeting ground 
where the end desired and achieved is the same, he points to the 
marked divergences with a fearless criticism of methods which 
psychoanalysis feels bound to supplement or even to supersede; he 
reveals the interpretative light which psychoanalysis is able to throw 
upon some of these older methods. Thus he speaks intelligently of 
the work of "experimental psychology," of its failures as well as its 



BOOK REVIEWS 257 

limited successes. He shows why a more vital psychology gives 
greater promise for human interests even while acknowledging the 
attempts of the earlier school. Pfister discusses psychoanalysis in 
the same manner in its relation to ethics and other philosophical or 
metaphysical fields. He also enters more fully into the matter of 
the unconscious and other psychoanalytic principles. He treats 
furthermore of the special contributions which certain individuals 
have made toward psychoanalysis or in related fields of psychology. 
He presents many practical forms of problem which have demanded 
psychoanalytic attention. His work is well illustrated with material 
from his own experience to lend weight to his merely theoretical 
presentation. Here is a work all analytically interested students can 
read with stimulus and profit. 

Stekel, Wilhelm. Onanie und Homosexualitat. 2d Edition 
Improved and Enlarged. Urban and Schwarzenberg, Berlin and 
Vienna, 1921. 

Stekel has turned again to the treatment of certain important phases 
of the psychosexual life and the problems that they present to the 
psychotherapist. He has given in this book a separate discussion of 
onanism or masturbation and of homosexuality as of two phases of 
far more prevalence and importance than had once been considered. 
He is interested with their place within the development of every life 
especially as the increasing pressure of modern civilization rests 
heavily upon the growth and the exercise of the sexual instinct. 
Onanism is an inevitable and a useful outlet in a direct form or in an 
indirect displaced form at some time in the individual development, 
perhaps more or less continuously. Homosexuality is not only a 
natural phase of development but becomes accentuated, becomes in 
some lives perhaps inevitably established because of the increased 
pressure of the conflict between the sexes. It may be an expression 
of an intensified sadistic attitude growing out of an early hatred di- 
rected toward the opposite sex. This too is a condition which becomes 
more intensified as civilization drives the sexes farther apart. Stekel 
is not unmindful of the many intricacies and variations in the building 
of the homosexual attitude and its finding expression in the neuroses. 
These vary in the relation to either parent, in individual experiences, 
in the course which the individual may follow in his adjustments or 
in the building up of his neurosis. The problem is a complex one. 
One may not agree with Stekel's emphasis upon the impulse of hate 
as a primary thing or in full with his attitude of approach to the 
problem. Yet his review of the situations in regard to both his 
subjects helps to bring the importance of these matters before us as 
actually existing and widespread factors in every life. They are 
of pressing importance for the psychoanalyst. Therefore the dis- 
cussion and clinical material here presented add to our knowledge and 
insight. 




DR. PEAECE BAILEY 



DR. PEARCE BAILEY 

It is a sad duty to chronicle the death ot\Dr. Pearce Bailey at 
his home in New York on February 11 after a week's illness with 
pneumonia. He had a similar attack two years ago from which he 
fully recovered. 

Dr. Bailey was born in New York July 12, 1865. After gradu- 
ation from Princeton in 1886 he began the study of medicine at 
the College of Physicians and Surgeons. After taking his degree 
there he served as interne in St. Luke's Hospital and studied abroad 
in Paris and Vienna before settling down to practice neurology in 
Xew York. He was one of the assistants at the Vanderbilt Clinic 
under Prof. Starr and became later [1906-1910] Adjunct Professor 
of Neurology at Columbia. He occupied the position of consulting 
neurologist to the New York, Roosevelt, St. Luke's, Orthopedic, 
Manhattan State and St. John's Hospitals. He served as President 
of the New York Neurological Society for two years, and later was 
President of the American Neurological Society. He was with Drs. 
Collins and Fraenkel one of the three founders of the New York 
Neurological Institute, the only hospital for nervous disorders in 
the United States. During his incumbency in these various posi- 
tions he wrote many valuable papers on neurological subjects which 
were published in various medical periodicals and sometimes col- 
lected together as in the case of some volumes of records of the 
Neurological Institute. His book, Accident and Injury, Their 
Relation to Disease of the Nervous System, was published by the 
Appletons in 1898 and remains to this day an authoritative work on 
the subject. 

There are three directions in which his work carried him that 
may be considered outstanding landmarks in his career : The Neuro- 
Psychiatric Service of the World War ; the work on Mental Defec- 
tives for the State of New York, and the Classification Clinic, three 
accomplishments of great importance, three achievements which will 
distinguish him in medical history. 

Surgeon General Gorgas called Dr. Bailey to Washington as we 
entered the war and asked him to take charge of the Neuro-Psychia- 
tric Service of the vast and growing army of the United States. 
He was the head of this department throughout the war, attained 
the rank of Colonel and received the distinguished service medal in 

259 



260 OBITUARY 

recognition of his work. He created a new department in our 
armies, one that had to do with careful selection of men, the elimina- 
tion of the unstable and unfit, the segregation later and the medical 
treatment of those who failed to keep their morale or fell victims 
to neuropsychiatric disorders. The success of the department in 
this country and overseas is too fresh in our minds to be forgotten. 
His work in the department formed the basis for the extreme 
psychological tests inaugurated later by others. 

At the close of the war he accepted the appointment of chairman 
of the New York State Commission for Mental Defectives at the 
hands of Governor Smith, and continued in the office at the solicita- 
tion of Governor Miller. He has accomplished much for the 
amelioration of conditions in institutions for the feeble-minded, laid 
the foundations for future progress in State supervision and care, 
and it is owing to him that a new State institution to segregate the 
defective delinquent has just been established at Napanock. 

The third accomplishment of his life, and perhaps destined to be 
his most important achievement, was the inauguration of the so-called 
Classification Clinic in East 80th Street. It was his dream that 
there should be psychological laboratories for the purpose of exam- 
ining all young people, normal and abnormal, in order to determine 
their mental standing, their efficiency, their aptitudes, to ascertain 
whether from the standpoint of human economy a young man or 
young woman should be given college training, and to discover if 
possible what vocations they should follow. This is no doubt a 
beginning in a great field of psychological service to the State, and 
it was his belief that ultimately every University would have such 
laboratory centres, to which the whole people might have access. 

Outside of his strictly medical work, Dr. Bailey had a wide 
interest in the arts and literature. As one of the founders of the 
Charaka Club [a club whose membership is made up of physicians 
with interests in medical history, the arts and letters], he was a 
frequent contributor to the pleasure of its meetings through essay, 
short story or play, and his writing was characterized by an unusu- 
ally clear cut, finished and dramatic style. Some of these contribu- 
tions are to be found in the printed volumes of transactions of the 
Charaka Club. 

His death leaves his two sons and two daughters, all under age, 
orphans, as their mother died over ten years ago. 

Dr. Bailey was a rare man in point of honor and integrity of 
character, an example of loyalty to friends, a hater of the merely 
plausible and insincere. Of Huguenot extraction, he had much of 



DR. PEARCE BAILEY 261 

the old-time Marquis about him, the lean aristocratic features and 
figure, the eagle eyes which saw through everything, the keen, quick- 
intelligence, the rapier-like wit, the cynical humor, the courage to 
endure many sorrows, the sensitiveness of a gentle, tender, generous 
human soul. 

Frederick Peterson. 



PEARCE BAILEY. 

We are not alone in mourning the death of Pearce Bailey. His 
influence had extended itself into such widened circles that many 
must testify to the loss that is suddenly felt among us. Only one 
week of illness with pneumonia removed him from the very midst 
of his activities in which he was fruitfully engaged. Yet it is in 
accordance with the spirit of quiet fortitude in the face of calamities, 
which could never turn him from his self-contained devotion to his 
activities, that we too should turn our attention from his death to 
his life. The former stirs us to a sense of personal grief which is 
a deserving tribute to the man who has gone in and out among us. 
Yet his life is that which he has given us, and in the further promot- 
ing of its activities we efface the sense of mere loss. 

Pearce Bailey was a man whose personal traits of character 
made the sort of impress which was a quiet reminder of the endur- 
ing virtues, as gentle yet sure in its influence as were the words with 
which he brought that influence to bear directly upon us. His 
activities, moreover, particularly those of the later years of his life, 
were of so definitely serviceable a nature, so promotive of needed 
reform, that our best tribute is the enlistment of our interest upon 
his unfinished work. 

Pearce Bailey was born in New York City in 1865. He received 
from Princeton University in 1886 the degree of Bachelor of Arts. 
In 1889 he completed his course of study at the College of Physicians 
and Surgeons, Columbia University, receiving the degree of Doctor 
of Medicine. His studies were supplemented by medical work in 
Vienna, Munich and Paris. He had turned his medical interest 
chiefly to the field of neuropathology and organic neurology, 
although his attention was also directed to traumatic and surgical 
phases of neurology. His one book, published in 1898, and remain- 
ing a standard to this day, deals with traumatic questions. Its title 
is Accident and Injury; Their Relation to Diseases of the Nervous 
System. He wrote also many papers, monographs and brochures 
upon neurological subjects, these in later years showing increasing 



262 OBITUARY 

interest in neuropsychiatric problems. In most recent years, in con- 
nection with his wider social service in neuropsychology, his ready 
pen as led him into articles of a still more popular character whereby 
he has sought to arouse the public to the practical sociological side 
of neuropsychiatric problems. Notable among these articles is the 
one in a recent issue of the New York Tribune in which he demands 
attention to the question. " Shall the State Kill Children ? " His 
writing is a protest against the execution for murder of two citizens 
of the State who though adult had the intelligence of the age of 
6 years. He was one of the editors of the "Archives of Neurology 
and Psychiatry " at the time of his death. He was a writer of dis- 
tinction in the non-medical field, having a warm play of imagination 
with a keen dramatic instinct in the writing of short stories. Even 
in these there was more than a mere literary charm, for it was inev- 
itable that there should be a profound even though lightly delicate 
touch upon some of the psychological problems that exist in men 
and women. Perhaps his intellectual power with his brilliancy of 
writing is nowhere in greater evidence than in his study of " Voltaire's 
Relation to Medicine " found in the Annals of Medical History 
for 1918. 

Doctor Bailey's early occupation with neurology led him to the 
Vanderbilt Clinic, where he was made Chief of the Clinic and later 
Adjunct Professor of Neurology in the College of Physicians and 
Surgeons, of which the clinic is a part. At the time of his death 
he held the post of consulting neurologist to St. Luke's, Roosevelt, 
New York and other hospitals in New York City. He was Presi- 
dent of the New York Neurological Society in 1903 and 1904 and 
at one time President of the American Neurological Association. 
He was a member of the American Medical Association, of the 
Pathological Society, and of the New York Academy. He was also 
on the Commission of the Associatio.n for Research in Nervous and 
Mental Diseases. 

His chief energies were given in the past to the establishment 
and development of the Neurological Institute, the only institution 
of its kind upon the American Continent. This was the develop- 
ment of an idea conceived and carried out by him in connection with 
Doctor Collins and Doctor Fraenokel. The usefulness of such a 
concentration and coordination of neurological facilities and forces 
proved itself, as this became the starting point of the wider service 
developed from it when the World War called our troops to its 
service. It was then Pearce Bailey who assumed the chief burden 
of organizing such service for this unexpected extension of activities. 



DR. PEARCE BAILEY 263 

He showed himself indefatigable in his investigation into methods 
and means for the carrying out of so gigantic a task. He mani- 
fested an administrative ability which soon received recognition from 
Washington in the call to definite service as head of a Neuro- 
psychiatric Department, an organization which owed its recognition 
as an integral part of preparation for war and for the health of the 
troops to the work which Doctor Bailey had already carried forward. 
It was his ability also to see a problem in its entirety, to grasp quickly 
all its possibilities and the responsibilities that resulted from these, 
that led to the development of the service in the lines which came 
to distinguish it. These were the elimination of the psychically and 
nervously unfit, who without such keen investigation as they now 
received could too easily pass muster. They were also the care and 
reconstruction of such as had broken down psychically under the 
severe tests which actual service put upon them. The value of his 
services was attested by his appointment to the rank of Lieutenant- 
Colonel and later to the full rank of Colonel. At his dismissal he 
was awarded the Distinguished Service Medal. 

The activities in this war service led Doctor Bailey on into other 
important fields. The determination and the intellectual keenness 
which he gave to these new projects stamp them as monuments to 
his own original personal genius for practical service. His work 
with the men of the army gave impetus to a similar type of work 
toward which his interest tended, that of the establishment of a 
Classification Clinic to be a department of the Neurological Institute. 
This clinic was to help adolescent boys to find their most effective 
place in life, to measure their capacities for different fields of work, 
and to discover whether they were fitted for college education or not. 
For Doctor Bailey based his idea upon the psychological distinction 
which must inevitably exist between different individuals and which 
the conventionalized standards of society too grealty overlook. He 
wanted to eliminate the failures which occur because what is ex- 
pected of boys and girls is not measured according to their actual 
and greatly varying individual capacity. His hope was that such 
a work would in time extend itself into a chain of laboratories of 
investigation with at least one in connection with each University. 

Meanwhile he was urged to enter a field of service for the State, 
a field which was new and difficult but which therefore demanded 
just the wisdom, courage, broad vision and initiative which were his. 
So he was made Chairman of the New York State Commission for 
Mental Defectives from which Dr. Walter K. James had recently 
resigned. His most marked accomplishment in this service was the 



264 OBITUARY 

attainment at last of the segregation of defective delinquents which 
he maintained should not be treated with or as ordinary criminals. 
So the establishment of a new State institution at Napanock for 
just such segregation became a definite result of his efforts. He did 
much besides in awakening interest to this important phase of social 
duty. He not only directed the attention of the State authorities 
and of the general public toward it, but he actually set in motion 
those definite projects for supervision and care of the feebleminded 
which have already brought about amelioration of the conditions 
that surround them in the institutions for their care. His work has 
been specially commented upon by Governor Miller of New York, 
under whom he continued in office, having been first appointed by 
Governor Smith. 

Pearce Bailey was distinguished by a character unswerving in 
its high principles. This character was always the same, therefore, 
in its impress no matter in what relationship it was manifested. As 
Chief of the clinic, in the hospital ward, in organization and carrying 
out of his larger activities, the same qualities commanded the coop- 
eration and the sincere respect of his colleagues or of those working 
under his direction. The same might be said of his friendships. 
Loyalty, sincerity, broad-minded tolerance of others even when they 
were in fault, kept him always affectionate toward his friends. 
Insistence upon the same sincerity in others and genuineness in 
mastery of facts characterized his direction of the work of others. 
His ready humor, even though cynical at times, was yet always 
gentle and kindly. His clear intellect could turn his ready sense of 
fun into telling wit when occasion required. Yet this was never a 
weapon to wound. His spontaneously generous spirit was able 
rather to enlist the hearty enjoyment even of the one whom the 
humorous attack might involve. He could not endure falsehood, 
insincerity, sham; even the outpourings of ungrounded enthusiasms 
offended him. Yet he was never the bitter opponent but he had a 
reserved attitude which brought conviction through the integrity of 
his own character, on which it was based, and through his own 
quiet assurance in his point of view. 

He had a keen intellect and one which grasped a problem in its 
entirety. At the same time he was never hasty in making a diag- 
nosis or in assuming a theoretical attitude without his own broad 
consideration of facts. Even then there was no arbitrary finality to 
his convictions. As a teacher he expounded in the same clear, con- 
vincing manner though he had no particular pedagogical aptitude or 
interest. He had a receptivity of mind as facile as was his varied 



DR. PEARCE BAILEY 265 

means of expression. The ability to originate and develop such 
means of expression seemed to increase rather than diminish in his 
later years. In his earlier years it might have been objected that 
he was too ready to take up a new interest and as easily lay it down. 
But he has proved himself both tenacious and efficient enough in 
matters which were worthy of pursuit and which contained possi- 
bilities of development for the future. 

Pearce Bailey was by birth and cultivation a man of genuine 
nobility. Though reserved, his personality was not separated from 
his fellows. His qualities were actual forces which inevitably ex- 
panded themselves in a hospitality toward other men and toward 
the impressions of experience to bear fruit in a service of present and 
future possibilities. He met with great losses in his own life. As 
they were never permitted to check his usefulness toward society 
so our loss is the incentive to take up the work that he has left. 
Only through such a continuation of his activities can the promise 
that he foresaw grow to fruitful fulfilment. 

Smith Ely Jelliffe. 



DR. PEARCE BAILEY 

Death has claimed Pearce Bailey. On February 11th, after a 
week's illness, contracted in the performance of his duties to the 
State's indigent defectives^ he succumbed. This terminated a life 
that was full of unselfish work for the advancement of his fellow- 
men. 

Dr. Pearce Bailey was born in New York, July 12, 1865. He 
graduated at Princeton University in 1886 with the degree of Bach- 
elor of Arts and from Columbia University, College of Physicians 
and Surgeons, in 1889, with his degree of Doctor of Medicine. He 
spent some time abroad at various times, chiefly in Paris and later 
in Munich with Krapelin. His activities in his earlier years were 
at first in purely neurological fields ; after having graduated at the 
College of Physicians and Surgeons he interested himself in the 
neurological clinic of that University, where he became successively 
Chief of Clinic and Adjunct Professor of Neurology. Dr. Bailey 
was President of the New York Neurological Society in 1903 and 
1904. Later, in recognition of the necessity for a neurological 
hospital in this city, he became one of the founders of the Neuro- 
logical Institute — to this day the only institution of the kind on the 
American continent. He was also consulting neurologist to St. 
Luke's, Roosevelt, New York and other hospitals at the time of his 



266 OBITUARY 

death. Dr. Bailey was a member of the American Medical Asso- 
ciation, former President of the American Neurological Association, 
President of the New York Neurological Society, member of the 
Pathological Society and of the New York Academy of Medicine. 
He was also on the Commission of the Association for Research in 
Nervous and Mental Diseases. Dr. Bailey devoted his energies to 
the development of the Neurological Institute with all the force and 
vigor and initiative that in him lay; and the wisdom of his course 
and that of his colleagues in the recognition of the necessity for such 
an institution was borne out from the very entrance of America 
into the great war, for it became one of the important centres in the 
country for the instruction of medical officers in neurology and neuro- 
psychiatry. Pearce Bailey was appointed to the Surgeon General's 
office with rapid promotion to a colonelcy, in charge of the neuro- 
psychiatric department — a new venture in modern warfare, and 
indicative of a tremendous advance in the selection and medical care 
of troops. He soon became the chief exponent of the importance 
of the proper elimination of the unfit and of the reconstruction of 
the disabled, shell-shocked troops; and for his brilliant service to 
the country Congress awarded him the Distinguished Service Medal. 
• After his retirement from the Army, Dr. Bailey, again with a 
spirit of self-sacrifice, undertook to establish the Classification 
Clinic — a department of the Neurological Institute — through whose 
means he looked to help adolescent boys make the most of their 
possibilities in life by a proper measurement of their capacity for 
different fields of work, especially with a view to separating the 
college-fit from the others. At the same time he was appointed by 
the Governor of the State to the Chairmanship of the State Com- 
mission for Mental Defectives. He was indefatigable in his attempts 
to make the State accept the difference between mentally defective 
delinquents and criminal delinquents, and his efforts to have these 
classes separated were being crowned with success when his time 
came. 

Those of us who have known Pearce Bailey intimately realize 
the irreparable loss that his absence means, not only to American 
medicine, but to all who valued truth, independence of thought and 
fearlessness in its expression. Pie was the foe of sham; he never 
could bring himself to listen without evident impatience, or to read 
without chafing under it, the outpourings of the impractical, the 
hyperbole of the self-deluded enthusiast. Governor Miller of New 
York State said of him : " Dr. Bailey was a man who possessed the 
very rare combination of public spirit, broad vision and practical 



DR. PEARCE BAILEY 267 

common sense." Nothing was more characteristic of him, after 
some long defence of a far-fetched, fanciful diagnosis by some mem- 
ber of his staff at rounds, than his smiling, indulgent query, " Do 
you really believe it yourself ? " It was said so gently and smil- 
ingly, with no hint or suspicion of irony, that even the victim joined 
in the hearty laugh that followed. This indeed was one of Pearce 
Bailey's great qualities — he told the truth at all times fearlessly, 
regardless of consequences, but never in a way that hurt. And he 
always told it interestingly, with charm and grace of manner and 
speech. He never wasted words; indeed, some of his communica- 
tions were more than laconic. One postal, mailed from the Surgeon 
General's office to the Military Director of the Neurological Insti- 
ture, in answer to a request for a report on a certain medical officer, 
contained the following : " N. G. per S. G. P. B." We all 
loved him ; on regular division rounds there was always the eager 
question, " Isn't the Chief coming to-day? " with disappointment on 
every face if the answer were, " Not to-day." He personally helped 
every one of his staff in every possible way; he practically never 
found fault in words, but his expression of countenance when his 
orders were not carried out, his evident feeling that he was not being 
properly assisted, made the guilty man so ashamed of himself that 
no other reprimand was necessary. 

His analysis of a case at the bedside was interesting. He spent 
the larger part of the time in getting a complete history of the salient, 
the essential facts. His physical examination was quite secondary. 
It was part of his theory in diagnosis that the history was the all- 
important matter — most cases that could be diagnosticated at all could 
be determined from the history — and the examination was but a 
check on the historical interpretation. At least, the history would 
delimit the case within reasonable bounds. It was surprising to see 
how successfully Dr. Bailey's theory worked out when he himselt 
carried out the examination. He was broad-minded and would 
allow any member of his staff to voice his opinion about a case even 
though diametrically opposite to his own; but reasons would always 
have to l)e advanced — and good ones — or by a few trenchant words 
he would \ie completely sulxlued But the utmost good humor 
prevailed always. 

Many of the meetings of our societies were graced by his genial 
presence. His presentations were always of the highest intellectual 
character, and he was a master at bringing at once into prominence, 
by some ably coined phrase, the point to which he wished to draw 
attention. One of his very latest articles, that appeared in the 



268 OBITUARY 

New York Tribune a few weeks ago, had for a title, " Shall the 
State Kill Children ? " At once the query became a plea to save 
from capital punishment those adult criminals that had the intelli- 
gence of the child. He had a way of going at once to the salient 
points of a discussion, avoiding all side questions and issues. He 
was an ardent searcher for the truth and discarded everything that 
seemed merely adventitious to such search. 

The sorrows that Pearce Bailey knew in his private life were 
many ; at no time was he free from them — there was no respite, but 
none could see their reflection depicted on his countenance, and few 
knew. 

There is appended hereto a list of the many brochures, mono- 
graphs and papers of which he was the author. They vary from 
earlier reports in the field of pathological neurology to the recent 
publications in neuropsychiatry. His one book, which still is re- 
garded as authoritative in its field, was first published in 1898 — 
Accident and Injury; Their Relation to Diseases of the Nervous 
System. He was also one of the editors of the "Archives of 
Neurology and Psychiatry." 

The Charaka Club, which boasts of such members as S. Weir 
Mitchell and Sir William Osier, also knew Pearce Bailey, one of its 
founders, as one of its brightest intellects. His stories and plays, 
which frequently graced the pages of its publication, were always of 
dramatic virility and force. " What he wrote for us was unique in 
its style, in its keen psychological analysis and dramatic finish, and 
has an enduring place in our hearts." 

Dr. Bailey was the son of William E. Bailey and Harriet B. 
Pearce. His wife, who died some ten years ago, was Edith Block 
of New York City. He is survived by two sons and two daughters. 

We, his friends and associates in New York City, are deeply 
conscious of the great loss we have sustained in the death of Dr. 
Pearce Bailey. His keen intellect, his wit and humor, his integrity 
of purpose and character, his attainments in the fields of neurology 
and neuropsychiatry, in the service of our country, compel our pro- 
found admiration ; and we wish to express and record herewith our 
deep grief at the loss of a colleague, a friend and a great American. 

Walter Timme, M.D. 



DR. PEARCE BAILEY 269 

BIBLIOGRAPHY. 
Three cases of Brown-Sequard paralysis, with remarks on the sensory 
tract in the human spinal cord. (N. Y. M. J., March 9, 1895.) 

Valvular disease of the heart in tabes. (J. Nerv. & Ment. Dis., May 

1895.) 

A case of general analgesia with symptoms of sclerosis of the pyramidal 
tracts and of the column of Goll. (Md. Rec, Dec. 28, 1895.) 

Report upon two cases of tumor of the spinal cord unaccompanied by 
severe pain. Read before the New York Neurological Society, Jan. 7, 1896. 
(J. Nerv. & Ment. Dis., March 1895.) 

Results of thyroid treatment in sporadic cretinism. (Peterson, Frederick 
& Bailey, Pearce.) (Pediatrics, May 1, 1896.) 

A contribution to the study of acute ascending (Landry's) paralysis. 
(Bailey, Pearce & Ewing, James.) (N. Y. M. J., July 4 and II, 1896.) 

The diagnosis of idiopathic epilepsy. (Amer. Medico-Surg. Bull., Aug. 
8. 1896.) 

The effect of early optic atrophy upon the course of locomotor ataxia. 
(Med. Rec, Nov, 14, 1806.) 

Clinical and pathological report of a case of cerebral syphilis. (Brewer, 
George & Bailey, Pearce.) (J. Cutan. Dis., 1896.) 

Primary fo.cal haematomyelia from traumatism. A frequent but often 
unrecognized form of spinal cord injury. (Med. Rec, Nov. 19, 1898.) 

The medico-legal relations of traumatic hysteria. (Med. Rec, March 4, 
1899.) 

Golebiewski, Ed. Atlas and epitome of diseases caused by accidents. 
Edited by Pearce Bailey. Phi la. W. B. Saunders, 1900. 54 p. 

Comparative physiology of faith cures. (Med. News, June 7, 1902.) 

Certain clinical types of brain syphilis. (Med. Rec, June 21, 1902.) 

Vertigo in neurological diagnosis. (Med. News, Nov. 1, 1902.) 

Fracture of the base of the skull ; neurological and medico-legal con- 
siderations. (Med. News, May 16, 1003.) 

Delirium from nervous shock. (Med. News, Aug. 27, 1904.) 

Pathological changes in fracture — dislocations of the spine. (Med. Rec, 
March 23, 1907.) 

The traumatic neuroses. A psychological mosaic. (N. Y. M. J., Jan. 8, 
1910.) 

Some recently described symptoms in spinal cord tumors. (Med. Soc 
March 12, 1910.) 

The dependence of neurology on internal medicine. A plea for the estab- 
lishment of neurological hospitals and of neurological wards in general hos- 
pitals (Collins, Joseph & Bailey, Pearce.) (J. A. M. A., July 30, 1910.) 

Tumors of the pineal body. With an account of the pineal syndrome. 
The report of a case of teratoma of the pineal and abstracts of all pre- 
viously recorded cases of pineal tumors. (Bailey, Pearce & Jelliffe, Smith 
Ely.) (Arch. Int. Med., Dec. 1911.) 

Spinal decompression. Reports of seven cases and remarks on the 
dangers of and justification for exploratory operations. (Bailey, Pearce & 
Elsberg, Charles.) (J. A. M. A., March 9, 1912.) 



270 OBITUARY 

Painless tumors of the spinal cord. (J. A. M. A., July 4, 1914.) 

Thaw and the law's of insanity. N. Y. 1916. 2 1. 

The heroin habit. (New Republic, April 22, 1916.) 

Laminectomy with simple exposure of the spinal cord. Its effect on the 
reflexes and on the symptoms of spinal disease. (Elsberg, Charles & Bailey. 
Pearce.) (J. A. M. A., June 10, 1916.) 

The hospital treatment of simple chorea. (N. Y. M. J., Sept. 23, 1916.) 

Expert medical testimony in criminal cases. (N. Y. State J. M., April 
1917.) 

Efficiency and inefficiency — a prolem in medicine. (Mental Hygiene. April 

1917-) 

The care of disabled returned soldiers (Mental Hygiene, July, 1917.) 
Voltaire's relation to medicine. Ann. of Med. Hist. N. Y. 1918. Vol. 1, 

P- 54- 

Care and disposition of the military insane. (Mental Hygiene, July 1918.) 

War neuroses, shell shock and nervousness in soldiers. (J. A. M. A., 
Dec. 28, 1918.) 

Addresses . . . upon the occasion of the dedication of Stewart Hall 
and the laying of the corner stone of the new service building at Letchworth 
Village, Thiels, N. Y., July 9, 1919. (Smith, Alfred E., Vanderlip, Frank 
& Bailey, Pearce.) Albany, N. Y., J. B. Lyon Co., 1919. 15 p. 

War's big lesson in mental and nervous diseases. Young men who 
thought they were sick formed one class of cases described by doctor who 
directed army's psychiatric section. A warning to public health officials. 
(N. Y. Times, Sept. 14, 1919) 

Crime and defectives. Better provision must be made for large per- 
centage of mentally irresponsible. (N. Y. Times, Dec. ?, 1920.) 

BOOKS. 

Accident and injury: their relation to diseases of the nervous system. 
N. Y., D. Appleton & Co., 1898, xii, 430 p. 

Diseases of the nervous system resulting from accident and injury. 
N. Y. & London, D. Appleton & Co., 1906, 627 p. ; idem. 2nd ed. N. Y.. 
D. Appleton & Co., 1909, 627 p. 






WILHELM ERB. 

The death of Wilhelm Erb in 1921 at the age of 81 removed one 
of the best known figures in German neurology. This place he had 
won ' not merely by the important work he had accomplished but 
from his distinct personality. This expressed itself in his manner 
of work and in the clarity and certainty with which he obtained his 




I.K PROFESSEUR ERB 
(d 'Heidelberg) 



results. These same elements stamped all his personal relations. 
They marked him as a man who was a representative leader in the 
field of exact science. Erb set his face against everything tending 
to a mystic reliance on the unknown. His science was like his own 
character, a matter of surrender of impulsive speculation, of mere 
tendency in hypothesis, to the austere guidance of the law of in- 
tellect. His creed was one of action upon circumstances, never of 
passive dependent faith or submissive inaction. 

271 



272 OBITUARY 

He was interested in direct observation valuing only that which 
could be actually brought under sense perception. Yet in accepting 
such material in the interests of his science he knew how to coordinate 
it, rearrange it in interpretative form and so to make clear problems 
hidden under confused symptomatic pictures or definitely to further 
progress in the realm both of anatomical and clinical research. His 
scientific severity of ideal gave him the aspect of gruffness but this 
only concealed a kindliness which belonged to his genuine interest 
in his work and in those who shared with him the advance of 
neurology. His interest in his patients as in the students to whom 
he was an inspiration was that of a sincere scientist and a genuine 
lover of humanity. He was peculiarly fitted to be a thorough clinical 
investigator, a sure diagnostician and an inspiring teacher. 

Erb was born in Bavaria in 1840. He entered the University of 
Heidelberg at the age of 19. From there he proceeded to Erlangen 
and took his degree finally at Munich in 1864. He returned to Heid- 
elberg as teacher of medicine and for a time was director of the 
Medical Polyclinic at Leipzig. Most of his life was spent in service 
at Heidelberg where he was made Professor Ordinarius in 1880 and 
Director of the Medical Clinic in 1883. He was sought after by 
Bonn, Leipzig, Vienna and Berlin but preferred to devote his life 
to the service in Heidelberg. 

He contributed many writings to the subject of internal medicine 
but he is best known for his special contributions in the knowledge 
of nervous disease. He published many monographs among which 
may be mentioned his works on "Tabes Dorsalis", "Der Thomsensche 
Krankheit (Myotonia congenita) Dystrophia muscularis progres- 
siva". Larger works are his "Handbuch der Krankheiten der peri- 
pheren cerebrospinalen Nerven", "Handbuch der Krankheiten des 
Riickenmarks und des verlangerten Marks". Important also is his 
"Handbuch der Elektropherapie". Many other writings might be 
mentioned from his active pen. He edited with von Bergmann and 
von Winckel Kolkmann's "Sammlung klinischer Vortrage" and was 
one of the founders and editors of the "Deutsche Zeitschrift fur 
Nervenheilkunde". 



VOL. 55 APRIL, 1922 No. 4 

The Journal 

OF 

Nervous and Mental Disease 

An American Journal of Neurology and Psychiatry. Founded in 1874 



Original Articles 



DELIRIUM ACUTUM AND PRIMARY SINUS 
THROMBOSIS* 

By Prof. Dr. K. Herman Bouman and Dr. B. Brouwer 

AMSTERDAM, HOLLAND 

The pathological anatomy of the syndrome Delirium acutum has 
already been studied by many investigators. The special reason 
why we once more call attention to the changes in the central ner- 
vous system in such cases is> that we have occasionally found in the 
post mortem examination an extensive thrombosis of the sinuses of 
the brain. This thrombosis was non-purulent and belongs to the 
group of the primary autochthonous form. The usual causes of sinus 
thrombosis (anemia, etc.) were missed in our patients and therefore 
we have examined the central nervous system in detail. To begin 
with we shall describe two of the most typical cases. 

Case I. Historia Morbi of Mrs. L. : age 50 years. 

The patient was admitted to the Psychiatric Ward of the Wilhel- 
mina Hospital (Amsterdam), suffering from nervous fears and 
melancholia. The family physician reported, that the patient during 
the last weeks was in a state of constant restlessness, and that, 
although very weak, had tried several times to leave her bed. He 
wrote that she spoke incoherently and unintelligently and that she 
was unapproachable. She had constant hallucinations, seeing 
flames, believing that the people about her were dead and floating in 
the air. She was in a state of anxiety the whole day and did not 
sleep. The husband reported that the patient had been ill for four 

* From the Psychiatric-Neurological Clinic of the University of Am- 
sterdam (Wilhelmina Hospital). 

[273] 



274 



K. HERMAN BOUMAN AND B. BROUWER 



weeks. Before marriage she was always bright, but during the preg- 
nancy of the first child she became depressed and tried to commit 
suicide. After confinement she got better, but occasionally after- 
wards had a new attack of melancholia, with intervening periods of 
mania. She had suffered from rheumatism but otherwise had no 
. ailment. An uncle was an idiot ; there were no other cases of ner- 
vous or mental disease in the family. 

On admission to the Hospital the patient was very thin. She 
was restless and anxious and in constant movement, but did not 
speak. She gave no answer to the questions put by the doctor and 
resisted every attempt to touch her. At first there was a slight rise 
of temperature, but after a few days this fell. 

The motility was normal : there were no contractures, tremors or 
choreic movements. The reflexes were increased, but no other neu- 
rological symptoms were found. The patient had optical hallucina- 

Figure i. 




Hemorrhage in the cortex. 
Weight-Pal Section.) 



tions, daily seeing flames ; she refused food and had to be fed arti- 
ficially. 

This condition remained stationary for seven days, but then the 
temperature suddenly rose again. The patient became very ill, was 
short of breath, moaning a good deal. The general condition was 
bad, but neurological symptoms were never evident. A rash ap- 
peared on her chest and back. No changes were noted in heart and 
lungs. She got much worse and ten days after admission she died. 

The post mortem examination by Dr. Hammer showed the fol- 
lowing : There was an extensive thrombosis in the sinus longitudinal 
superior extending for two-thirds of the length of the sinus for- 
wards. The thrombi were red. There were also many thrombi 
found in the veins of the pia, which on both sides enter the sinus. 
The dura mater was adherent. There was edema of the brain sur- 
face, but no other alterations, especially no softening. 

The following was noticeable in the internal organs. The heart 



DELIRIUM ACUTUM 



275 



was slightly atrophied, but not dilated, without any symptoms of in- 
flammation. A slight atrophy of the lungs was found, no tubercu- 
losis, no pneumonia. The spleen was small, flabby and anemic. It 
was a typical infection spleen. The liver was also small and flabby. 
A little ulcer with scars was found in the stomach, some diverticula 
were present in the mesenterium. There were many arteriosclerotic 
scars in the kidneys, but no nephritis. There was a catarrhal in- 
flammation of the prelum with many hemorrhagic spots, containing 

Figure 2 



*%r* 




HHI 1 



Pyramid cell of the Gyrus centralis 
anterior showing the " acute 
cell disease of Nissl." 



purulent fluid and also a catarrhal inflammation of the bladder. 
There were no other pathological changes in the body. 

Dr. Hammer examined the blood; its composition was normal, 
but many cocci were found, most of these being of chain formation, 
with four or six links, some of these lying in red or white blood cells. 

The pathologic-anatomical diagnosis was : Thrombosis sinus 
sagittalis durac matris ct venae piae rnatris. 

Atrophia fusca cordis. Atrophia hepatis ct pulmonum. 

Lien infectiosus. Pyelitis et cystitis catarrhalis. 

Arteriosclerosis retiuni. Diverticula mcsoitcrialia intestini. 



276 A'. HERMAN BOUMAN AND B. BROUIVER 

Thus a certain degree of sepsis was found. The post mortem 
examination revealed no distinct cause of the sinus thrombosis. It 
may have been the result of the pyelitis, which caused the slight sep- 
sis. As however pyelo-cystitis is repeatedly found in general in- 
fections of the body, it may equally well be an accompanying symp- 
tom. 

When we come to the more minute examination of the brain, no 
anomalies in the sulci and gyri were discovered. In cutting the cere- 
brum in a frontal direction, several small pointed hemorrhages 
were found in the white matter at the convexity of the brain, more 
especially in the neighbourhood of the thrombosed veins. In some 
places (e.g., at the right gyrus parietalis) these small dotted hemor- 
rhages had formed themselves into a big brownish-red spot. 

Sections were made of several parts of the central nervous sys- 
tem and coloured to various methods. The chief results are as fol- 
lows : 

Microscopical Description 

Sections coloured after Weigert-Pal, van Gieson and with hemo- 
toxylin-eosin show, that the blood vessels of the cortex are wholly 
rilled and that many erythrocytes had penetrated through the walls. 
The hemorrhages are limited to the cortex and the immediately un- 
derlying white matter, near to the thrombosed veins ;. they are miss- 
ing in the deeper parts (Fig. i). All the hemorrhages are of very 
recent date, the blood elements being still unchanged. It seems that 
the number of vessels is slightly multiplied. The walls of the ves- 
sels are unchanged. The pia mater is also hyperemic ; in several 
places large cells with great nuclei, somewhat resembling plasma 
cells are present, especially along the walls of the blood vessels. 
They are also found in the pia of the cerebellum. Marchi sections 
of the gyrus angularis show many black grains in the neighbour- 
hood of the hemorrhages ; no secondary degeneration, however, can 
be observed. 

Toluidine sections are made of many places of the cortex and of 
the deeper regions of the central nervous system. This method 
also makes it clear, that the hemorrhages are of very recent date. 
Sometimes quite normal cells may be found in the midst of the hem- 
orrhages. The nerve cells in the direct neighbourhood of these 
bleedings are not more changed than in the other parts of the cortex. 

We shall now give a more detailed description of several parts of 
the central nervous system. 

Gyrus centralis anterior. There are no big hemorrhages. No cell 
changes are found in the lamina zonalis; a few only in the lamina 



DELIRIUM ACUTUM 



277 



granulosa externa. Here and there poorly coloured cells without the 
normal tigroid are seen. But in the lamina pyramidalis the changes 
are very distinct : the greater pyramid cells show the " acute cell dis- 
ease of Nissl " very clearly (Fig. 2). The dendrites are to be traced 
at a longer distance than is usually the case, the tigroid bodies are 
only coloured, the nucleus is swollen and often lies against the wall 
of the cell body. Many of these degenerated cells are surrounded by 
glia cells, others are very poorly coloured and almost invisible, several 
being wholly wanting. The glia is increased and is in many places 
seen in rows along the blood vessels. In the lamina ganglionaris 
the giant cells of Betz are almost wholly wanting. Wherever seen, 
they show intensive degeneration. The glia in these deeper layers 
is not so strongly augmented as in the lamina pyramidalis. In the 
lamina multiformis only uncertain changes are here and there visible. 





Figure 3 




r*r- 


*""• 


u 


¥& *' 


% 


w 


w 




*' 









Blood Vessel with Ameboid- glta- 
cells. (Alzheimer Section.) 

In the gyrus frontalis superior of both sides, the alterations are 
on the whole still more marked than in the former gyrus. Hemor- 
rhages in the shape of small dots are everywhere found, in the cor- 
tex as well as in the underlying white matter. All the vessels are 
very full, but the walls are normal : there are no perivascular in- 
filtrates. The lamina zonalis shows scarcely anything special, and 
also in the lamina granularis externa the alterations are still insignif- 
icant ; in some spots the cells have lost their tigroid. But in the 
lamina pyramidalis not a single great nerve cell is normal and here 
also the smaller pyramid cells are altered. Many of the larger cells 
are almost wholly degenerated and a good many must have disap- 
peared. The most frequent form of degeneration in these pyramid 
cells is the " acute cell disease of Nissl." There is a distinct in- 
crease of neuroglia in these layers. We could not find mitoses in the 
glia cells. In both the deepest layers, many cells are also altered. 



278 K. HERMAN BOUMAN AND B. BROUWER 

In the gyrus angularis there is also a distinct hyperemia without 
alterations of the walls of the blood vessels. The number of cells 
suffering from the " acute cell disease of Nissl " is smaller than in 
the above mentioned gyri. The superficial layers of the cortex 
are normal, but in the third and fourth layers the "acute cell dis- 
ease" reappears and several cells are almost wholly degenerated. 
Only the larger cells are altered and even of these many are un- 
changed. There is a slight increase of the glia cells. In the deepest 
layers of the cortex scarcely any changes are visible. 

Also in the gyrus temporalis I only the large pyramid cells show 
changes : the glia is here unaltered. In the gyrus occipitalis I sev- 
eral degenerated larger cells are found in the third and fourth 
layer and here and there some of these must have disappeared. In 
this region of the cortex also no augmentation of the neuroglia is to 
be noted. In the regio calcarina all the smaller cells are very well 
coloured, but in several places the greater cells show very clearly 
the " acute cell disease of Nissl," and there is a slight increase of 
the glia. In the gyrus supramarginalis the changes are generally 
somewhat greater than in the occipital region of the brain. Even in 
the lamina granulans perfectly evident diseased cells are found near 
totally healthy ones. The " acute cell disease of Nissl " appears in 
many of the big pyramid cells of the third layer. In this region 
also the reaction of the neuroglia is insignificant. In the cortex of 
the cornu ammonis the hyperemia is less clear. The above described 
typical cell changes are present Only in a small number of cells. 

What strikes one in the cerebellum is the very great changes in 
the Purkinje cells over the whole cortex. These cells are vaguely 
coloured, the tigroid bodies are wanting, the nucleus is often swollen. 
Only here and there a Purkinje cell of the normal colour is found. 
The other cell forms are normal, except at some places, where there 
are slight alterations of the greater cells of the zona molecularis. 
More glia cells than usual are collected around the Purkinje cells. 
The cells of the nucleus dentatus are normal. 

We could not find anything special in the cervical spinal cord. 
The medulla oblongata (region of the nuclei hypoglossi and of the 
olivae inferiores) seems to be undisturbed, except that there is a 
great quantity of yellow pigment in the cells of the oliva inferior. 
The hyperemia is insignificant. Also the region of the midbrain 
scarcely shows hyperemia. In the cells of the nuclei trochlearis the 
acute cell disease is again found at some places. No cell changes 
are visible in either the optic thalamus or in the corpus striatum. 



DELIRIUM ACUTUM 279 

Bielschowsky sections, made of several regions of the cortex, 
where the above mentioned acute cell disease is found, show a dis- 
tinct alteration. The intracellular network is poorly coloured, in 
many cases even, no longer visible ; the nuclei of the cells are scarcely 
distinguishable, or have disappeared. The intercellular tissue, on 
the contrary, is very well impregnated. 

We have further examined the condition of the neuroglia in sec- 
tions, made according to the neuroglia method of Cajal and espe- 
cially by the different methods of Alzheimer. In many places of 
the cortex cerebri, we observed a slight enlargement of the neuroglia 
fibres (Cajal). According to the method of Alzheimer, especially 
with his methods A and C, ameboid cells are found in several re- 
gions. Especially in the gyrus frontalis superior, the gyrus centralis 
anterior and the gyrus occipitalis I such glia cells were met with. 
They appear chiefly in the neighbourhood of the small hemorrhages, 
especially in the perivascular spaces of the small vessels (Fig. 3). 
However the number of such ameboid glia cells is not so great as we 
expected to find in delirium acutum. 

We also examined more carefully the condition of the plexus 
choroideus, because several authors (von Monakow and others) 
have observed great changes of this tissue in different cases of psy- 
chosis. In our case, the arteries and the veins are overfilled with 
blood, but the cells of the villi of the plexus choroideus are quite 
normal. No infiltrates, no symptoms of sclerosis nor other patho- 
logical marks could be found. Special sections of several blood ves- 
sels of the central nervous system (arteria basilaris, etc.) did not 
show any alterations. 

Case II. Historia Morbi of Miss M., aged forty years, unmarried. 
Profession : matron of an orphanage. The patient was admitted to the 
psychiatric ward of the Wilhelmina Hospital (Amsterdam), suffer- 
ing for several months from nervousness. She had been over- 
worked and needed rest. For some time she had been unable to do 
her work satisfactorily, sleeping badly and complaining of a heavy 
feeling in the head. 

Her past history is as follows. As a child she had had scarlet 
fever, but was otherwise healthy ; as a girl her intellect was good, 
but she was very nervous. She studied to become a teacher but 
tailed, owing to her nervousness. Five years ago the patient had 
an attack, similar to the present, from which she quickly recovered. 

Her antecedents are as follows : the father died from heart dis- 
ease, the mother being healthy. Her sister suffered from the same 



280 K. HERMAN BOUMAN AND B. BROUWER 

illness, having had a serious attack of depression and died in the 
Wilhelmina Hospital. There are no other cases of nervous or 
mental disease in the family. 

At the examination she had a vacant stare, said little, and did 
not cry. Now and then she asserted that lately God had not been 
helping her in her work. 

Her condition on admittance is as follows. The general physi- 
cal health is good, she is not anemic. The psychical examination 
shows that she is cognizant of time, place and persons. It is diffi- 
cult to draw and keep her attention. Her temperament is depressed. 
There are no hallucinations. She pays little attention to her sur- 
roundings and is inactive. She is not cataleptic, there is no mutism 
or negativism. 

As regards the intellect there are no disturbances. Her mem- 
ory is very good. Her school knowledge is better than she imagines. 
Her judgment and power of criticism are normal. 

The neurological examination shows no defect. The speech is 
good. The motility and sensibility are normal. There is only 
a slight trembling of the fingers. The reflexes of the extremities 
and of the abdomen, as also the reaction of the pupils, are normal. 
There is nothing abnormal in the heart and lungs. The Wasser- 
mann reaction in the blood is negative. 

The patient remained in the same condition for a fortnight, be- 
ing depressed and anxious, and not showing other symptoms. Then 
a fairly sudden change occurred, symptoms of fear increased, she 
became restless, frequently left her bed and made constant move- 
ments, repeatedly blowing her mouth. Yet she was aware of her 
surroundings. The patient perspired freely yet there was no fever 
and the pulse was normal. Hot baths and medicine lessened the 
feeling of anxiety, but the general condition became less satisfactory. 
The twentieth day ofter admission the temperature rose to 41.5° C, 
the pulse 100, the following days the temperature remained equally 
high. Nothing special was found in the heart, lungs and abdomen. 
The reflexes showed no alteration. The diazo reaction was nega- 
tive. The facial expression showed signs of anxiety. She con- 
stantly muttered unintelligibly and did not answer when questioned. 
She did not do what was asked and forcibly resisted being examined. 
She was in constant movement. A rash appeared all over the body. 
On the following days the temperature remained above 40° C, the 
psychical condition was stationary, but the patient got worse, and, a 
week after the temperature increased, the patient died. 



DELIRIUM ACUTUM 281 

The post mortem examination showed the following results : 

A quantity of blood was found on the surface of the left hemi- 
sphere of the brain. The left sinus petrosus inferior and trans- 
versus were almost completely obliterated by large thrombi. The 
left temporal and occipital lobe showed a softening with tiny blood 
spots surrounding it. No pathological changes were found at the 
base of the brain or on the bones of the skull and the organs of hear- 
ing were normal. The brain weighed 1245 grams. There was 
nothing special in the formation of the sulci and gyri. The ex- 
amination of the internal organs had the following results. There 
was a slight brown atrophy of the heart, but no dilatation and no 
endocarditis. The aorta manifested scleroses of a small degree. A 
tablespoonful of clear yellowish fluid was found in the pericardium. 
The examination of the lungs showed no signs of tuberculosis or 
pneumonia. The liver was somewhat atrophied. Further there 
was an infection spleen. There were some adhesions in the peri- 
toneum. The other organs showed no pathological alterations. 

The pathologic-anatomical diagnosis was : Thrombosis sinus trans- 
versi et petrosi inferioris sinistri. Encephalomalacia rubra lobi 
temporalis et occipitalis sinistri. Atrophia fusca cordis ct hepatis. 
Lien infectiosus atrophicus. Arteriosclerosis aortae. 

The post mortem examination did not give a definite explana- 
tion of the cause of the thrombosis. 

There is much blood upon the left hemisphere, partly also sub- 
pial, extending from the frontal lobes to the occipital pole. A part 
of the left temporal gyrus is wholly destroyed and softened. Also 
at the base of the brain a bloody infiltration is visible. The right 
hemisphere is free from thrombi and blood. 

In cutting the brain in a frontal direction it is clear, that the 
softening is limited to the cortex of the left temporal lobe and that 
the deeper lying parts of the central nervous system are free. The 
cornu ammonis and the gyrus fusiformis, for example, are not de- 
stroyed. 

Microscopic Investigation 

Weigert-Pal and van Gieson sections show that the softening of 
the left temporal lobe must be of very recent date. There are 
many small hemorrhages in the neighbourhood of the softening spot. 
Also in the pia mater of this region fresh hemorrhages are visible. 
No secondary degeneration in the direction of the optic thalamus, 
either with the Weigert-Pal, or with Marchi method is visible. 



282 



K. HERMAN BOUMAN AND B. BROUWER 



With the latter many black grains are found in several parts of the 
cortex cerebri. In the toluidine sections the following facts are 
noted. In the gyrus centralis anterior the pia mater is slightly 
swollen. The blood vessels are all filled up with blood. Between 
the meshes we see again these peculiar big cells — also mentioned in 
our first case — which resemble plasma cells and sometimes mono- 
nuclear leucocytes. In the cortex itself there is also hyperemia, but 




Fig. 4. Chronically altered pyramid cells of the gyrus 
centralis anterior. 



there are no hemorrhages. The lamina zonalis is normal, and the 
cells of the lamina granularis externa show only little changes. But 
in the next layer many diseased pyramid cells are found. They are 
poorly or faintly coloured, the nuclei are swollen and degenerated, 
the tigroid bodies are not quite visible. In many cells the nuclei are 
wanting. In the deeper layers of the cortex the same is the case, 
and it is remarkable that the giant cells of Betz are almost totally 
absent. Only in some places there is found a degenerated re- 



DELIRIUM ACUTUM 283 

mainder of these cells. Many cells of this gyrus show the " acute cell 
disease of Nissl " but there is also another type of degeneration visi- 
ble. Several cells are very long and small, the dendrites are visible 
far off, thin and extended. These cells are very darkly and dif- 
fusely coloured, with a nucleus scarcely visible or wholly wanting 
1 Fig. 4). They are not infrequently met with in groups, sometimes 
in the immediate neighbourhood of cells suffering from the acute 
cell disease (Fig. 5). They resemble cell alterations, found in cases 
of several chronic psychoses (dementia praecox) and have a dis- 
tinct character. In the lowest layers of this gyrus scarcely any al- 
terations can be found. 

Generally speaking, the reaction of the neuroglia is very mode- 
rate; many of the larger ganglia cells have a number of "traban- 
cells " at their base (Fig. 6), but only in some places a slight increase 
of the number of glia cells can be seen. There are no mitoses. 

In the gyrus frontalis superior many small hemorrhages besides 
the hyperemia are present. The alterations in the nerve cells are 
still more pronounced than in the gyrus centralis anterior. In the 
lamina pyramidalis a normal cell is scarcely found and also the 
smaller cells are degenerated. Most of these show the " acute cell 
disease of Nissl" (Fig. 7). But in several spots also the above 
mentioned cell degeneration of more chronic character is seen. 
Very likely many cells have wholly disappeared. Also in the deeper 
layers of this gyrus diseased cells are visible. There is a clear in- 
crease of the number of glia cells in the lamina pyramidalis. 

In the gyrus frontalis medius and inferior of both sides there are 
also intensive alterations in the nerve cells, but only those of an 
acute character. 

Many parts of the gyrus temporalis I of the left side have been 
so destroyed by the hemorrhages, that it is not possible to judge the 
condition of the cells. Where there are no hemorrhages, the altera- 
tions are still very intensive, although the hyperemia is sometimes 
insignificant. The cells of the lamina zonalis appear to be normal, 
but in the lamina granularis externa a number of small cells is 
distinctly suffering from acute cell disease. In the third and fourth 
layers nearly all the cells are degenerated. In several places the 
chronic form of degeneration is seen. In the deepest layers the 
acute cell disease is much less frequent. The alteration of the glia 
is less marked than, for example, in the gyrus frontalis superior. 

In the right gyrus temporalis I. where there is no big thrombus, 
the changes in the cells are much slighter. Only the larger pyramid 



284 K. HERMAN BOUMAN AND B. BKOUWER 

cells manifest the acute cell disease; here and there the changes of 
more chronic character are scarcely found. The neuroglia is not 
increased to any extent. 

In the gyrus temporalis medius, of the same side, the number of 
diseased cells is much greater. There are no " chronically " altered 
cells ; they are found, however, in the third temporal gyrus, which is 
otherwise in the same condition as the second temporal gyrus. 

In the regio occipitalis of both sides it is remarkable that the 
sections of the regio calcarina show much slighter disorders in the 




Fig. 5. Cells with acute and with chronic gyrus 
degeneration. (Centralis anterior.) 



nerve cells than in the gyrus occipitalis I. In the former only the 
larger cells in the third layer are degenerated, in the latter many 
small cells as well as the greater are affected. But nowhere in the 
occipital lobe are alterations of the above described chronic char- 
acter visible, and the neuroglia is almost normal in this part of the 
cortex. 

Small groups of these chronically altered cells are met again in 
the gyrus fusiformis I, and the cornu ammonis, in which also several 
greater cells show the typical acute degeneration. 

In the cortex of the cerebellum the same condition is found as in 
our former case. Many of the Purkinje cells are degenerated, and 



DELIRIUM ACUTUM 



285 



the glia around these cells is increased. The other cells of the cere- 
bellum are quite normal. 

In the medulla oblongata many cells of the oliva inferior con- 
tain yellow pigment ; it is doubtful whether this is abnormal. In 
the other parts, however, many larger cells show the acute degenera- 
tion, for example the large cells of the nuclei reticularis, of the nu- 
cleus hypoglossi, etc. Here and there, also, cells with more chronic 
degeneration are visible. In the midbrain, the optic thalamus and 
the corpus striatum cell degenerations are also clearly seen; the glia 
is only increased in the optic thalamus. 

Bielschowsky sections show the same characteristics as in the 




Fig. 6. Degenerated Cells with tra- 
bant cells. 



first case, but to a greater degree. The intracellular network has 
disappeared in the acute diseased cells. In the cells with the degen- 
eration of a more chronic character on the contrary, this network is 
coloured very dark. 

In studying the sections, made after the neuroglia method of 
Cajal, it seems that there is a slight increase of the glia fibres in 
several places of the cortex cerebri, but mostly there is no distinct 
difference from normal sections. Contrary to the first case, no 
ameboid glia is found by the Alzheimer methods. 

Toluidine sections of the plexus choroideus show hyperemia; all 
the blood vessels are over full. At some places small hemorrhages 
are present. The cells of the epithelium, however, still remain un- 
altered. The walls of the blood vessels do not show anything ab- 



286 K. HERMAN BOUMAN AND B. BROUWER 

normal in the whole central nervous system. There are no perivas- 
cular infiltrates found in the nerve tissue. 

Briefly to sum up the chief points, in the two cases of delirium 
acutum in patients suffering from manic-depressive psychosis, we 
found extensive primary thrombosis of the brain sinus with hemor- 
rhages in the cortex. The microscopic investigation of the brain 
showed besides, in many places, great changes in the nerve cells. 
In the first case only the " acute cell disease of Nissl " is found, sev- 
eral cells having also wholly disappeared ; in the second case degen- 
erations of a more chronic character were also visible. In connection 
with the examination of the internal organs we must conclude that 




Fig. 7. Cell with acute cell disease of Nissl. 
(Gyrus frontalis superior.) 

a severe acute infection had been at work. The origin of this infec- 
tion could not be sufficiently determined. 

The question now arises, what was the connection between the 
delirium acutum and the primary sinus thrombosis? Has the lat- 
ter caused the former? Such a sinus thrombosis is very rarely 
found in typical cases of delirium acutum. A case somewhat re- 
sembling ours is described by Schroder (1909). After childbirth 
a woman showed catatonic and deliriant symptoms. In the post 
mortem examination an extensive sinus thrombosis was found in the 
brain, and many cells of the cortex showed the acute cell disease of 
Nissl. 



DELIRIUM ACUTUM 287 

It is known that the primary sinus thrombosis shows clinically 
many variations and not infrequently this is found in the post mor- 
tem examination without there having been any symptoms during life- 
Von Monakow, who has given a fine description of this subject in 
his Gehimpathologie mentions, that in severe cases disturbances of 
the consciousness, delirium and several symptoms of irritation of 
the central nervous system (convulsions, etc.) are seen. Not unfre- 
quently the clinical image resembles acute meningitis (Voss). In 
the newer literature we have not been able to find any fresh point 
of view on the clinical side of this subject. A summary of the more 
recent bibliography has been collected by Lewandowsky. It is clear 
that the difficulties are at present also very great in making a correct 
clinical diagnosis. Remarkable in this connection is an observation 
by Riggs, who had a patient operated upon for tumor cerebri; the 
post mortem examination showed that there was only an extensive 
primary sinus thrombosis. 

Primary or autochthonous sinus thrombosis does not occur so 
frequently as the purulent type, which, as is well known, is mostly 
caused by inflammation of the auditory organs. The former, how- 
ever, springs from quite different Causes, namely in many diseases 
accompanied by severe marasmus. The primary sinus thrombo- 
•sis is seen in cases of tuberculosis pulmonum, nephritis, heart dis- 
ease, enteritis (especially in children), typhus, pneumonia, cancer, 
influenza, appendicitis, malaria, several diseases of the blood. We 
have personally seen such a thrombosis in a patient suffering from 
severe chlorosis with serious psychical disturbances, in meningitis 
tuberculosa and in dementia paralytica. As a great exception Rein- 
hold has described this affection in chorea minor. 

Opinions differ as to the cause of the sinus thrombosis, just as in 
the other thromboses of the body. Various investigators attach 
great significance to the fact, that the blood flows more slowly in the 
sinus of the brain, but it is certain that this cannot be the real cause. 
The majority of authors ascribe the cause to infection, which dam- 
ages the endothelial cells of the walls of the sinus, through which 
small thrombi arise. Katzenstein has studied this in detail and has 
detected in several cases microorganisms which had caused the in- 
fection. Although infection may be the most frequent cause of the 
sinus thrombosis, yet it does not seem absolutely necessary always 
to accept this. In blood diseases and in marantic conditions it is 
probable that the vasa vasorum of the sinus are underfed, hence 
leading the degeneration of the endothelial cells. 



288 K. HERMAN BOUMAX AXD B. BROUWER 

It sometimes occurs that none of the above mentioned affections 
are in evidence. The most thorough examination of such cases has 
been made by Therman. He found by the microscopic investiga- 
tion of the brain extensive and intensive changes of the nerve cells 
in the cortex and concluded that there was always in these brains a 
meningoencephalitis. He believes that the sinus thrombosis was 
not the origin, but the consequence of this encephalitis. 

Our idea about the cases we have examined, is that the delirium 
acutum is not caused by the primary sinus thrombosis, but that both 
affections are the result of one cause. The results of the histologi- 
cal investigation contradict the conclusion, that the delirium acutum 
was the clinical expresson of the sinus thrombosis. Then in both 
cases we found hemorrhages that must have been quite recent, be- 
cause the red blood corpuscles were not altered. This was also in 
the thrombosed veins. We saw further intensive degeneration of 
nerve cells in several parts of the central nervous system, with no 
thrombosis. This alteration of the ganglia cells had in many re- 
spects the same character as is found in cases of delirium acutum 
without sinus thrombosis, as will be described in the next pages. 
We believe that the body has been infected, with the result that the 
central nervous system has also suffered. In the last days before 
death the endothelium of the sinus has also been injured, by which 
thrombus was created. It is probable that this has been favoured 
by the marasmus and by the hyperemia in the brain. The sinus 
thrombosis in this case is accidental : it has perhaps hastened death, 
but has no further value for the analysis of the pathological anat- 
omy of delirium acutum. 

In reviewing briefly the literature on the subject of the delirium 
acutum, we would state that this syndrome may occur in the course 
of different psychoses (in manic-depressive psychosis, exhaustion- 
psychosis, infection- and intoxication-psychosis, collapse, delirium, 
dementia paralytica, etc.). Many investigators believe that we 
must regard this delirium acutum as the result of meningo-encepha- 
litis acuta. The appearance of hyperemia, hemorrhages, degenera- 
tions of the nerve cells and perivascular infiltrates has led them to 
this conclusion (Binswanger and Berger, Kozowsky and others). 
This encephalitis should, in that case, be of toxic origin, all the more 
because repeatedly microbes are found (Bianchi and Piccinio, Res- 
onico, Mills, Potts and Burlett, Hunt, Potzl and Wells). Yet one is 
struck by the fact, that the real symptoms of inflammation in the 
brain are often missing. Hence many workers avoid the word en- 
cephalitis (Alzheimer, Hanes). Another striking fact is that the 



DELIRIUM ACUTUM 289 

anatomical results vary much, especially when the condition of the 
neuroglia is taken into account. There are cases where increase of 
neuroglia is very marked ; there are others where this is insignificant 
(Alzheimer) Gruhle and Ranke). The most typical alteration 
found in recent times is the acute cell disease of Nissl. It has 
also been found in our cases. In both the acute cell disease 
of Nissl dominated, but in the second case we found also 
alterations of the nerve cells of a more chronic character, as is seen, 
for example, in dementia praecox. This leads us to believe that 
some other disease had formerly affected the brain. It is generally 
accepted that besides the exogenetic cause there is also an important 
endogenetic source in most cases of delirium. In our second case 
this was very clear; not only did the chronically degenerated cells 
prove that the central nervous system had been previously weak- 
ened, but there has also been a family predisposition. A sister of 
this patient also died in our clinic of delirium acutum several years 
before. 

It does not seem correct to regard our case as encephalitis, be- 
cause the true symptoms of inflammation (especially perivascular 
infiltrates) were not present in the nerve tissues. The presence of 
the above described cells in the pia mater is not sufficient for the 
diagnosis of encephalitis. To explain the origin of the degenera- 
tion of the nerve cells we will not infer more than the following. 
A disturbance in the metabolism of the organism — more especially 
in the brain — had been caused by fever, acceleration of the blood 
circulation, toxins, etc. The feeding of the nerve cells was not thus 
so perfect. The degeneration in these cells must therefore be re- 
garded as a disturbance in the assimilation and dissimilation of 
the cell body. 

In the pathological anatomical investigation two points have 
claimed our attention. In the first place, the fact that, in both cases, 
the frontal area of the brain has suffered most, and, secondly, that 
amongst all the cells of the central nervous system, the bigger ones 
were most affected. 

In our second case, very intensive degeneration is also found in 
the left temporal lobe, but only in these regions where there is soft- 
ening. The lesion of the frontal brain, being otherwise greatest, is 
perfectly clear. To explain this fact it needs to be borne in mind 
that the frontal area of the brain is inclined to be affected by various 
diseases. This is very apparent in dementia paralytica, also in ar- 
teriosclerosis, and in different kinds of encephalitis. This tendency 



296 K. HERMAN BOUMAN AND B. BROUWER 

cannot be accounted for by being an affection in a special area of 
the brain, which is fed by one large blood vessel. The origin must 
be deeper. We believe that this fact, that the frontal area of the 
brain suffers so much in different diseases, is owing to its being a 
part of the cortex phylogenetically very young. We know that the 
parts of the central nervous system which belong to the younger 
areas have less power of resistance against damaging influences. 
Probably the physical chemical constitution of these regions is dif- 
ferent from other parts. 

As stated above the bigger ganglia cells undoubtedly suffer more 
than the smaller ones. This is not only true in the pallium, but also 
in the cerebellum and, in our second case, also in the lower parts of 
the central nervous system. In the pallium this is most evident in 
the areas where the acute cell disease was least severe, for example, 
in the regio calcarina. In this region it is very clear that only the 
larger cells were suffering. But also in the frontal brain, where the 
alterations are visible in the larger and in the smaller cells, it is not 
to be denied that the larger ones have suffered most. 

This fact is occasionally met in delirium acutum (see the de- 
scription by Cramer, Binswanger and Berger). It is, however, not 
always the case, as it is not to be wondered at, seeing that the de- 
lirium acutum is so often met with in other diseases, where the brain 
has already been damaged. 

To explain this one could argue that the alterations in the 
greater elements are easier seen than in the smaller. That is true, 
but in areas where the disease is very intensive, the changes can 
also be seen very clearly in the smaller cells. If we now inquire 
whether analogies of this feature are to be found in other diseases 
of the nervous system, the answer must be in the affirmative. This 
is very evident in cases of parenchymatous degeneration of the 
cerebellar cortex. In most of these it is striking that the Purkinje 
cells suffer first and most intensively. These great cells, indeed, 
degenerate in many different diseases of the central nervous system, 
and hence Abrikosoff concludes that these ganglia cells are the most 
vulnerable in the whole nervous system. The same feature is seen 
in acute poliomyelitis. Anatomical investigation shows that in the 
first days of the disease there is a meningo-myelitis. with a prefer- 
ence for grey matter. In such acute cases, affections of the blood 
vessels and infiltrates are seen throughout the whole of the grey 
matter (also in the white). But when the disease is more advanced, 
the remaining defect is limited to the anterior horn, where many 



DELIRIUM ACUTUM 291 

great cells have disappeared. The smaller cells in the posterior 
horn remain undisturbed. In the rare cases where a defect re- 
mains also in the posterior horns, it is then the greater cells of 
Clarke's column that are changed. 

The same applies to many other diseases of the spinal cord, for 
example, the spinal form of progressive nuclear atrophy, polio- 
myelitis anterior chronica, amyotonia congenita of Oppenheim, the 
disease of Werdnig-Hoffmann. We can also give an example of 
a disease of the medulla oblongata. In the chronic progressive bul- 
bar palsies, all the greater cells gradually disappear, while the small 
ones remain intact. Finally, we know that in the cortex the giant 
cells of Betz disappear early in different diseases. 

In short, there are many examples from which it appears that 
the greater cells are inclined to suffer more easily. Hence the ques- 
tion arises — also in connection with the results of our own investi- 
gations — whether the circumstances that the cell is large is not the 
cause of a greater vulnerability. We have already pointed out that 
the degeneration of the cells in our cases of delirium acutum is 
finally caused by disturbances in the metabolism. We are therefore 
led to inquire whether, perhaps, the process of metabolism is more 
difficult in these greater cells. In this connection we shall make use 
of the views of several biologists (Bolk and others). Namely, the 
fact, that in the phylogenesis the greater cells are inclined to disap- 
pear, is accounted for by the metabolism being more difficult. Such 
large cells as are found in the spinal cord and in the medulla ob- 
longata of the lower animals, are not present in higher vertebrates. 
When the size of a cell increases, its surface is raised to the second 
power, but its contents to the third. The surface increases rela- 
tively less quickly than the contents. The consequence of this is, 
that the assimilation and the dissimilation are more difficult in the 
greater cells, because these processes act on the surface. Hence a 
cell that functions very intensively must be small. 

Such an idea is attractive to an anatomist of the brain, because 
he knows that these parts of the central nervous system, that act 
very intensively and almost without stopping, mostly consist of 
smaller cells (sympathetic vagus cells, for example). It may there- 
fore be accepted that the greater cells in which d priori the meta-. 
bolism acts less easily, are the first to suffer, when there are dis- 
turbances of this process in the central nervous system. The rela- 
tive smallness of the surface of the cell is here the chief thing. 



292 K. HERMAN BOUMAN AND B. BROUWER 

Resume 

In this article two cases of delirium acutum have been described, 
occurring in patients suffering from " manic-depressive psychosis." 
In the post mortem examination a primary sinus thrombosis was 
found. The microscopical examination of the brain showed, firstly, 
that these thromboses were of recent date, having originated some 
days before death. It was not the cause of the delirium acutum, but 
both affections were the consequence of a general infection of the 
body. In both cases there were extensive degenerations in the nerve 
cells, mostly belonging to the type of the acute cell disease of Nissl. 
In the second case, changes of a more chronic character were also 
found Although there were differences in the histological details 
both cases agree in two points. Firstly, the lesion was most severe 
in the frontal area of the brain. This is explained by the circum- 
stances that this part of the brain is the youngest in phylogen- 
esis, and has, therefore, less power of resistance against noxious 
agents. Secondly, the greater cells showed more inclination to suf- 
fer than the smaller ones, as is the case in many other diseases of the 
central nervous system. This fact is explained by the circumstance, 
that in the greater cells the surface is relatively smaller, whence the 
processes of assimilation and dissimilation are more difficult. When 
disturbances in the metabolism of the central nervous system occur, 
these will first manifest themselves in the larger cells. 



BIBLIOGRAPHY 

a. Delirium acutum 
i. A. Alzheimer. Das Delirium acutum. Monatschrift fiir Psychiatrie und 
Neurologic Band II, 1897. 

2. A. Alzheimer. Beitrage zur Kenntnis der pathologischen Neuroglia und 

ihrer Beziehungen zu den Abbauvorgangen im Nervengewebe. His- 
tologische und histopathologische Arbeiten Nissl und Alzheimer, Band 
3, 1910. 

3. G. Ballet et M. Faure. Contribution a l'anatomie pathologique de la 

psychose polynevritique et de certaines formes de confusion mentale 
primitive. Presse Medicale, 1898. refer. Archives de Neurologie, 1899. 

4. O. Binswanger und H. Berger. Zur Klinik und pathologischen Anatomie 

der postinfectiosen und Intoxicationspsychosen. Archiv fiir Psychiatric, 
Band 34, 1901. 

5. E. Bischoff. Beitrag zur pathologischen Anatomie der schweren acuten 

Verwirrtheit. Allgemeine Zeitschrift fiir Psychiatrie, Band 56, 1899. 

6. L. Bouman. Die Histopathologic der Psychosen. Psychiatrische en 

Neurologische Bladen, 1918. 

7. A. Cramer. Pathologisch-anatomischer Befund in einem acuten Falle der 

Paranoia Gruppe. Archiv fiir Psychiatrie, Band 29, 1897. 

8. R. Finkelnburg. Ueber Meningoencephalitis unter dem klinischen Bilde 

des Delirium acutum verlaufend. Deutsche Zeitschrift fiir Nervenheil- 
kunde. Band 33, 1907. 



DELIRIUM ACUTUAI 293 

9. Gruhle-Ranke. Xissl's Beitrage. Band I, Heft 3, 191 5. 

10. E. L. Hanes. Acute Delirium in psychiatric practice, with special refer- 

ence to so called acute delirious mania (collapse delirium). The 
Journal of Nervous and Mental Disease, volume 39, 1912. 

11. A. Jacoh. Zur Symptomatologie, Pathogenese und Pathologischen Anat- 

omie der " Kreislaufpsychosen." Journal fur Psychologic und Neu- 
rologie, Band XIV, 1909. 

12. A. D. Kozowsky. Zur pathologischen Anatomie und Bacteriologie des 

Delirium acutum. Centralhlatt fiir allgemeine Pathologie und Patho- 
logische Anatomie, Band X, 1899. 

13. A. D. Kozowsky. Zur Pathologie des Delirium acutum. Allgemeine 

Zeitschrift fiir Psychiatric Band 68, 191 1. 

14. Potzl. Demonstration. Xeurologisches Centralhlatt, 1907. S. 870. 

15. E. Siemerling. Infektions- und autotoxische Psychosen (Deliren, Amen- 

tia). Zeitschrift' fiir artzliche Fortbildung, 191 1. 

16. Thoma. Beitrag zur Klinik und Pathologie akut letal verlaufender Psy- 

chosen. Allgemeine Zeitschrift fiir Psychiatrie, 1909, Band 66. 
17- E. Toulouse et L. Marchand. Lesions cerebrales dans un cas de delire 

aigu. Bulletin de la societe clinique de medicine mentale 7, pag. 165, 

1914. Referat : Zeitschrift fiir die gesamte Neurologie und Psychiatrie, 

Band II, 1915. 
18. G. Windhaus. Beitrag zur Lehre vom Delirium acutum. Dissertation, 

Kiel, 1909. 

b. Sinus Thrombosis 

1. H. Claude. La phlebite des Veines cerebrales. Revue de medicine, 

XXXI, 191 1. 

2. J. Katzenstein. Ueber Venenthrombose und hamorrhagische Enzephalftis 

im Anschluss an bacteriologisch-anatomische Untersuchungen bei Sinus- 
thrombose. Miinch. med. Wochenschrift, 191 1. 

3. M. Lewandowsky. Gehirnveneu- und Sinusthrombose. Handbuch der 

Neurologic 1912. 

4. C. von Monakow. Gehirnpathologie, 1897. 

5. H. Reinhold. Ein Beitrag zur pathologischen Anatomie der Chorea 

minor. Deutsche Zeitschrift fur Nervenheilkunde, Band 13, 1898. 

6. C. E. Riggs. Symptoms simulating brain tumor due to the obliteration 

of the longitudinal, lateral and occipital sinuses. A clinical case. 
The Journal of Nervous and Mental Disease, volume 34, 1907. 

7. P. Schroder. Anatomische Befunde bei einigen Fallen von akuten Psy- 

chosen. Allgemeine Zeitschrift fiir Psychiatrie, Band 66, 1909. 

8. E. Therman. Ueber die sogenannte primare Sinusthrombose. Arbeiten 

aus dem Pathologischen Institut. Helsingfors, 1905, Band I. 

9. W. Uhthoff. Ueber die Augensymptome bei der Thrombose der Hirn- 

sinus. Monatschrift fiir Psychiatrie und Neurologie, Band 22, 1907. 

10. F. Vorpahl. Ueber Sinusthrombose und ihre Beziehung zu Gehirn- und 

Piablutungen. Zieglers Beitrage zur pathologischen Anatomie, Band 55, 

I9J3- 

11. G. von Voss. Ueber die autochthone Hirnstnusthrombose. Deutsche 

Zeitschrift fiir Nervenheilkunde, Band 15, 1899. 

12. A. Wimmer. Ein Fall von ausgedehnter Thrombosierung der Hirnsinus. 

Berliner klinische Wochenschrift. 1906. 



PACHYMENINGITIS CERVICALIS (LUETICA) WITH 
UNUSUAL FEATURES* 

By Moses Keschner, M.D. 

ADJUNCT NEUROLOGIST, THE MT. SINAI HOSPITAL AND MONTEFIORE HOME, 

NEW YORK. 

A. H., 44 years old, white, a native of Austria, was admitted 
to the neurological service of the Mt. Sinai Hospital on August 
ii, 1920, complaining of pain and weakness of both upper extremi- 
ties, inability to use his arms, poor vision, especially in the left 
eye, tremor of the hands, frequent headaches and diminished 
sexual power. 

His family history is of no significance. 

His previous history except for an attack of gonorrhoea at 28 
is negative. 

Personal History. — Married at 38; his wife gave normal birth 
to three normal children, all of whom are alive and well. No mis- 
carriages. Syphilis denied by name and symptom. 

His habits are good. He never smoked or drank to excess. 

Present Illness. — About 10 years ago he began to have gastric 
disturbances, the exact nature of which cannot be determined; 
these ceased completely three years ago. Five years ago he began 
to have a "gnawing" pain and weakness in the right shoulder and 
arm. The pain was very severe and always worse at night; it 
lasted one year. The weakness was progressive and greatest on 
raising the arm. He also noticed that his shoulders and upper part 
of the arm began to grow thinner, the maximum thinness being 
reached at the end of two years. Eighteen months ago he began 
to have similar pains and weakness in the left shoulder and arm, 
which are also becoming progressively thinner, and at the time of 
admission the pain in them still persists. 

The patient states that during the last three years he has on 
numerous occasions seen " double," and that during the last year 
his eyesight has not been as good as before, especially in the left 
eye. For the last three years his sexual power has not been as good 

* From the Neurological Service of the Mt. Sinai Hospital, New York 
city. Presented at a clinical conference, Nov. 3, 1920. 

[294] 



PACHYMENINGITIS CERVICALIS 295 

as before. He frequently has headaches. These have no special 
localization and are not influenced by anything. Recently he has 
greatly been annoyed by a tremor in both hands. He occasionally 
has difficulty in controlling his bladder and rectum. 

Examination reveals a poorly nourished individual with no evi- 
dences of cardio vascular, renal or respiratory disease. There are 
no petechiae and no icterus. When he extends his arms a fine 
tremor is noticeable in the hands and fingers. This is probably due 
to muscular weakness. Fibrillary twitchings are noticeable in 
whatever musculature is left of his deltoids, pectorals, trapezii, 
and spinati. The myotatic irritability of the muscles of the shoulder 
girdle and arms is somewhat increased. 

His mentality is apparently unimpaired. There is no aphasia 
and no dysarthria. 

His visual acuity roughly tested shows no gross defects. There 
is no hemianopsia. Xo tests were made for color fields. 

Ophthalmoscopic examination by Dr. Wolf: Left eye: Large 
areas of medullated nerve fibers. Right eye: Small areas of medul- 
lated nerve fibers upward and nasally; otherwise fundi are normal. 
Pupils. — Both are small, miotic and irregular in outline but equal 
in size ; the left is fixed to light ; the right reacts slightly and 
sluggishly to light. Both react promptly to accommodation. There 
are occasional nystagmoid movements in both eyes, in the extreme 
horizontal position. No paralysis of convergence. No external 
ocular palsies. 

The right naso-labial fold is not as marked as the left one. 
There are no evidences of involvement of the remaining cranial 
nerves. 

Sensation. — Objectively there are no disturbances of superficial 
or deep sensibility, and no astereognosis. Subjectively he complains 
of sharp pains in the arms, and of headache. 

Motor Functions. — Deltoids weak, left more than right. Pec- 
torals weak, right more than left. Rhomboidei completely atro- 
phied. The strength of the levator anguli scapulae cannot be 
determined. Trapezii both weak. Sterno-cleido mastoids arc 
apparently normal. Subclavius cannot be tested. Supra and in- 
fraspinatus wasted on both sides. Subscapularis, wasting cannot 
be determined. Latissimus dorsi, weak on both sides. Teres 
major, weakness cannot be determined. Serratus magnus, right 
atrophied, left not involved. Triceps, wasted on both sides. Bicep* 
and coraco-brachialis, wasted on both sides. Supinator longus. 



296 MOSES KESCHNER 

both wasted. Extensors of the .wrist and fingers, weak on both 
sides. Pronators, not involved. Flexors of wrist and fingers, 
apparently not involved. Thenar, hypothenar, interossei and 
lumbricales not affected on either side. Both hand grips are weak. 

The motor functions of the remaining musculature are appar- 
ently normal. General myotatic irritability somewhat increased. 

F to N test poorly carried out, but this is due to the great 
muscular weakness in the arms. No ataxia. No cerebellar symp- 
toms. Station and gait normal. No Romberg. 

Reflexes: Superficial. — Corneals : present. 

Palatal: present. 

Abdominals: all but the lower right are markedly diminished. 

Bulbo-cavernosus : present. 

Cremasterics: lively and equal. 

No Babinski or any of its confirmatories. 

Deep. — Jaw jerk: lively. 

Pectorals, biceps, triceps, and radial — very lively on the left 
side and present, but diminished, on the right. 

KJ's: extremely lively on both sides. 

AJ's: lively; right greater than left. Occasionally ankle clonus 
can be elicited on the right side. — No Kernig. 

Sphincters: Patient states that he has some difficulty in starting 
urination. 

Laboratory Findings. — 

Blood Wassermann on two occasions suspicious (Mt. Sinai 
serological laboratory). Cerebro-spinal fluid: o.i to i c.c. Wasser- 
mann, 4 plus. Globulin, one plus. Five lymphocytes to the cubic 
millimeter. Fluid obtained under normal pressure. 

Urine. — Normal . 

Temperature. — Normal. 

Blood Pressure. — No difference on the two sides : 105/72. 

Electrical Reactions. — Dr. Harris reports: Faradic response in 
the shoulder girdle muscles and the arm of the left side is prompt 
but a stronger current is required. Galvanic response in the right 
shoulder girdle muscles is normal, while on the left side the response 
is prompt, but the ACC is greater than the KCC. 

There is no tenderness on percussion of the skull, spine or any 
other part of the osseous system. 

X-ray examination of skull, cervical and dorsal spinal column 
is negative. 

There are no vasomotor or trophic disturbances. 



PACHYMHXlSCms CERVICAUS 



*)7 



Bedside Notes. — 

Aug. 15, 1920, received intravenously arsenobenzol .4 gm. 

Aug. 21, 1920, received intramuscularly Hg. salicylate gr. .1. 




Note the wasting of the muscles of the shoulder girdle and both armi 
in contrast to the well preserved musculature of the rest of the body. 



Aug. 25, 1920, received arsenobenzol intravenously .4 gm. 
Aug. 29, 1920, received intramuscularly Hg. salicylate gr. .1. 
Aug. 30, 1920, discharged from the hospital with the following 



298 



MOSES KESCHNER 



note: Pains almost entirely disappeared. Beginning increase in 
power. Transferred to the dispensary for further anti-specific 
treatment. 

Sept. 9, 1920, blood Wassermann in the dispensary negative. 

The case may then be summarized as follows: A 44-year-old 
man began to have some vague gastric disturbances 10 years ago, 
which lasted until 3 years ago. Then he began to have "gnawing" 
pains and weakness in the right upper extremity (5 yrs. ago). 




Note the atrophy of both shoulder girdles, and the muscles of both arms. 

This lasted one year. He then began to have similar pains and 
weakness in the left upper extremity (18 months ago) which persis- 
ted up to the time of admission to the hospital. During the last 
year his vision (in the left eye) has not been as good as previously. 
For the last 3 years he has frequently had generalized headaches. 
His sexual power has been poor during the same period. Some 
years ago he had frequent urination for one week. His pains are 
always worse at night. Owing to his muscular weakness he has 
lately been incapacitated for work. 



PACHYMENINGITIS CERVICALIS 2& 

He presents the following positive objective findings : Pupillary 
changes, slight nystagmoid movements in both eyes ; some facial 
weakness on the right side; atrophy of the trapezii (slight); 
marked atrophy of the supraspinal, deltoids, biceps, triceps and su- 
pinators, especially the left, with weakness of all movements 
controlled by these muscles ; fibrillary twitchings in the muscles 
of the shoulder girdle, and partial R.D. in the involved muscles ; 
some sphincteric disturbances ; increased tendon reflexes in the 
lower extremities, with an occasional clonus in the right ankle ; 
a 4 plus Wassermann and an increased globulin content of the spi- 
nal fluid. 

On this history and findings the diagnosis of cerebro-spinal lues 
and pachymeningitis cervicalis was established. 

In making this diagnosis the following conditions have to be 
excluded : 

1. Amyotrophic lateral sclerosis. Pain in the arms, which is 
so marked a feature in our patient, is not a symptom of amyotrophic 
lateral sclerosis. The absence of a spasticity or rigidity in the 
involved extremities, as well as the absence of bulbar symptoms 
after five years' duration also speak against such a diagnosis. 

2. Spinal tumor. This can be excluded on the grounds that 
the patient shows evidences of cerebro-spinal lues, that there is no 
sensory level and no objective sensory disturbances. The duration 
of the disease, the absence of signs indicating increasing cord com- 
pression are all against such a diagnosis. As a general proposition, 
we may also add that the pain in spinal tumors is much more 
lancinating in character than in our case. 

The same diagnostic criteria are also applicable in the exclusion 
of circumscribed serous meningitis and circumscribed meningeal 
cysts. 

3. Syringomyelia. Against this diagnosis are, absence of spinal 
deformity, absence of sensory dissociation, absence of vasomotor 
phenomena and of trophic disturbances of the skin, bones and 
joints ; absence of oculo-pupillary symptoms, and the absence of a 
spastic paralysis of the lower extremities, and the fact that the 
muscular atrophy did not begin in the small muscles of the hands, 
as is usually the case in the Aran-Duchenne type of progressive 
muscular atrophy (commonly seen in syringomyelia of the cervical 
cord.) 

4. Multiple neuritis. The absence of any of the usual etiological 
factors of multiple neuritis, the absence of objective sensory changes 



300 MOSES KESCHNER 

and of nerve tenderness, and the increased deep reflexes in the lower 
extremities, are sufficient to exclude this condition. 

5. Chronic disease of the anterior horns of the cord, such 
as chronic anterior poliomyelitis, and chronic progressive muscu- 
lar atrophy are excluded by the absence of pains in the latter, 
and the presence of exaggerated deep reflexes in the lower extremi- 
ties in our patient, as well as by the presence of ocular symptoms. 

6. Tuberculous pachymeningitis. This condition may present 
a clinical picture not unlike that seen in our patient. The absence 
of evidences of tuberculous disease in the vertebral column and in 
other parts of the body, and the presence of evidences of syphilis, 
are sufficient to make the differentiation. 

7. Muscular dystrophy. In this condition there are no pains 
and no fibrillary twitchings, no R.D. and no increased deep reflexes, 
and no cranial nerve involvement. 

8. Brachial paralysis from cervical ribs. Radiography of the 
spine failed to show the presence of any supernumerary cervical 
rib, nor were there any evidences of inequality of the radial pulses 
such as are commonly found in this condition. 

Note. — Examination in the dispensary on January 27, 1921, 
after he has received three courses of intensive salvarsan and 
mercury treatments, show no new neurologic findings. Subjectively 
he feels much better. He has been free from pain for the last 
four months. The disease has apparently been arrested. At this 
writing he is still receiving antiluetic treatment. 

We may therefore conclude that this case is one of cerebro- 
spinal lues, the prominent features of which are a meningomyelitis 
involving C5, Cy and C8 segments of the cord, with participation of 
the anterior and posterior roots as well as the anterior horns at the 
same levels. The exaggerated knee jerks with tendency to ankle 
clonus on the right side seem to point some involvement of the 
pyramidal tracts. 

264 Seventh Street, New York City. 



Society Proceedings 



NEW YORK NEUROLOGICAL SOCIETY 

The Three Hundred and Ninety-third Regular Meeting 

Held at the Academy of Medicine, January 3, 1922 

The President, Dr. Foster Kennedy, Presided 

CHEMISTRY OF PHOSPHORUS IN BRAIN ACTIVITY 

[Author's Abstract] 

Dr. William H. Porter. Phosphorus in combination with soda 
serves the physiological economy in three distinct processes: ( 1) In 
connection with the digestive functions the trisodic phosphate is acted 
upon by the hydrochloric acid and converted into (2) a disodic mono- 
hydrogen phosphate which is the true alkalinizer of the body fluids 
and tissues. A high state of alkalinity is essential to perfect oxida- 
tion and assimilation. (3) After the disodic monohydrogen phos- 
phate has served its purpose in the body it is excreted through the 
kidneys, where it meets a molecule of uric acid and is transformed 
into the acid monosodic dihydrogen phosphate, the true acidifier of 
the urine. 

Phosphorus is found also in combination with calcium, magne- 
sium and potassium, the sodium and calcium combinations being most 
important. Phosphorus also reaches the body fluids and tissues in 
the form of lecithin, nucleoalbumin, nucleic acid, phytine, etc. Phos- 
phorus enters plant life as a phosphate to be synthesized into these 
highly complex bodies. 

The author's contention for years has been that oxidation reduc- 
tion takes place only in the fixed cells, as found in the various body 
glands, and not in the body tissues and fluids ; and that this process 
constitutes, in a large measure, the biologic activity of the body cells. 
In connection with these oxidation reduction processes and the exact 
place where they occur, it should be remembered that the ganglion 
cells of the nervous system are large masses of protoplasm resembling 
in composition, but not in shape, the cellular structures of the glandu- 
lar organs, and that, in all probability, they are the place at which the 
complex phosphorus-bearing lx)dies are oxidized and reduced. 

The reasons for this interpretation are that these protoplasmic 
masses are very abundant in the central nervous system ; that these 
phosphorus-bearing compounds are found in larger amount at this 
point than in any other parts of the body, and that there seems to be 
a decided generation of impulses originating in the central nervous 
system which control and regulate the automatic balance of the human 

[301] 



302 NEW YORK NEUROLOGICAL SOCIETY 

system, — a condition which could not be maintained if the nervous 
energy was due solely to reflected heat energy brought to the central 
nervous system by the centripetal nerves and reflected out again by 
the centrifugal nerves. Active working of the central nervous sys- 
tem is always accompanied by increased elimination of alkaline phos- 
phates, which fact tends to support the theory that these phosphorus- 
bearing bodies are oxidatively reduced in the cells of the central 
nervous system. Hence, increased elimination of the alkaline phos- 
phates indicates simple augmented physiological activity of the ner- 
vous system ; and overelimination of the earthy phosphates in a highly 
acid urine indicates a malnutrition involving chiefly the nervous 
mechanism. 

The answer to the question as to how these complex phosphorus- 
bearing bodies can be converted into energy and phosphates, and how 
they pass out of the system, is plain if the theory be accepted that 
the protoplasmic masses of the central nervous system have the 
power oxidatively to reduce this class of bodies. Assuming that the 
nerve cells possess this power, lecithin, for instance, is here reduced 
to phosphate of soda, urea, carbon dioxid and water. 

It is recognized that bone deficiency is not due to lack of lime 
salts or bone-producing elements, but to disturbance of metabolism 
which prevents fixation of the calcium salts. In the reduction of 
the phosphorus-bearing molecule it is reasonable to suppose that, for 
an instant, the phosphorus atom is free and exerts this oxidative 
stimulating action upon the protoplasmic masses, thus generating an 
inherent central nervous impulse, which not only augments the cell 
activity per se in which this change occurs, but is reflected to all 
parts of the economy by the nerve fibers springing from the cells. 

So far as known to the author, the production of disodic mono- 
hydrogen phosphate from these complex phosphorus-bearing com- 
pounds is a newly revealed fact, and gives to the physiological econ- 
omy an inherent source of this absolutely essential body alkalinizer. 
How much is produced in this manner daily is not known. 

A CASE WITH THE CLINICAL PICTURE OF MIDDLE 
FOSSA TUMOR: AUTOPSY FINDINGS 

[Author's Abstract | 

Dr. E. D. Friedman. John C, 11 years old. Admitted Novem- 
ber 13, 1921, to Bellevue Hospital; died December 11, 1921. 
Italian. Family history negative. Previous history : Normal deliv- 
ery and development. Present illness: Began five to six months ago 
with attacks of headache lasting about one day and recurring once 
a week. His condition remained unchanged for three and a half 
months. He then became bedridden, being unable to walk. Three 
weeks prior to his admission to the hospital he became drowsy and 
had nose bleed ; the right eye became bloodshot. Weakness of the 
right side of the face developed. There was no fever at any time. 
Three weeks ago, at the onset of one of his attacks, he was uncon- 



NEW YORK NEUROLOGICAL SOCIETY 303 

scious for a short time. His headache became constant but there 
were no bladder or rectal symptoms. He had complained of pain in 
the right side of the face and of double vision. The physical exam- 
ination showed an emaciated, pale boy, with a dry skin. Me was 
irri table and cooperated poorly in the examination. The physical 
examination showed no abnormal medical findings. The right pupil 
could not be examined, due to local conditions in the eye, the cornea 
being cloudy ; the conjunctiva was hyperemic. The left pupil w;i.» 
large and reacted poorly to light and accommodation. There were 
ptosis of the right upper lid and exophthalmos on the right, anaes- 
thesia in the distribution of the right fifth nerve, slight weakness of 
the right seventh of the lower motor neuron type, and limitation of 
ocular movements in the horizontal plane, more so on the right. 
I lea ring was normal. The tongue deviated slightly to the right. 
Abdominal reflexes were normal. Knee jerks were absent, ankle 
jerks were present. There was no Babinski sign, although the left 
plantar response was at times equivocal. Kernig's phenomenon was 
absent. The spinal fluid was bloody and under increased pressure. 
The Wassermann test was negative in both blood and spinal fluid. 
The right fundus could not be seen. The left fundus showed slight 
congestion of the veins. There was generalized wasting with hypo- 
tonia. There was no ataxia. Sensation as far as could be tested 
was normal. The nose bleed was accounted for by excoriation in the 
vestibule of the nose. There was no evidence of sinusitis. On the 
17th of November, 1921, there were generalized twitchings in the 
extremities. The spinal puncture was repeated, the fluid was still 
bloody and under increased pressure. The boy subsequently had a 
number of convulsive seizures, one lasting three minutes, the others 
of shorter duration. The x-ray examination of the skull showed 
evidence of increased intracranial pressure, the coronal and lamb- 
doidal sutures being pronounced. Erosion of the posterior clinoid 
processes was present. The floor of the sella was depressed. The 
urine was negative. The white cell count was 10,400. with 5 per 
cent polynuclear cells. The Von Pirquet test was negative. Patient 
was submitted to x-ray treatment without benefit. Operation was 
refused. 

The post-mortem findings showed excoriation in the left side of 
the nose, right exophthalmos and broncho-pneumonia, probably 
terminal. The findings in the skull are as follows: 

Brain : The calvarium is removed without difficulty and is some- 
what thin. The dura strips readily. The brain appears large for a 
child of 11 years. The convolutions are somewhat flattened on both 
sides. The brain is removed with difficulty. At the base of the 
brain there is an irregular mass of material which seems somewhat 
friable and contains plaques varying in size, most of them about 
1 mm. in diameter. This tissue is spread over the brain stem, the 
pons and the pyramids and extends backward to the cerebellum and 
into the interpeduncular space; it appears to l>e attached to the tissue 
filling the sella. On opening the latter it is seen to contain a mass 
of tissue which is somewhat blood stained, and mixed with blood 



304 NEW YORK NEUROLOGICAL SOCIETY 

clot. The latter extends forward into the ethmoid cells on the left, 
but there is no communication with the nasal cavity on the other side. 
There is marked erosion of the sella, also of the torcula. There are 
small areas of erosion over each temporal bone. There are one or 
two plaques on the lateral surface of the cerebral hemispheres. 

The right orbital fossa is somewhat large. On dissection of the 
right eyeball it was seen to contain an increased amount of vitreous 
humor ; otherwise it appeared normal. The final pathological 
diagnosis has not yet been made. 

The dominant findings in the case are those of middle fossa lesion 
on the right. (Ocular muscle palsies, anaesthesia in the distribution 
of the fifth with resulting neuro-paralytic keratitis and conjunctivitis.) 
There were slight evidences of extension of the process posteriorly 
(peripheral facial palsy and slight deviation of the tongue). There 
was also an apparent lesion of the internal fibers of the third nerve 
on the left but it is still to be noted that the findings outside of those 
pointing to the lesion of the right middle fossa were meager indeed 
when one considers the widespread character of the lesion. It is 
worth noting that there was no evidence of choked disc. This may 
have been due to the yielding of the sutures noted in the x-ray 
report. That intracranial pressure was increased was shown by the 
x-ray findings in the skull, the increased tension in the lumbar fluid, 
and possibly also the diminution of the knee jerks. The last is 
commonly seen in eases of hydrorrachis. The alternative explanation 
for the diminution of the patellar reflexes, that of possible injury to 
the cerebellar pathways, could not be demonstrated, although there 
is noted hypotonia of the musculature. The bleeding from the nose 
on the right side led us to consider for a time cavernous sinus throm- 
bosis, but this diagnosis was rapidly abandoned. The protrusion of 
the right eyeball was not adequately explained by the autopsy find- 
ings, but it has been noted very frequently in middle fossa tumors 
and may be due to irritation of the sympathetic filaments which inner- 
vate the so-called Lanstroem muscle surrounding the eyeball. 

Discussion: Dr. Foster Kennedy: Dr. Friedman has given this 
picture clearly, and one important thing that he said is the diminution 
and absence of deep reflexes in this case, and the possibility of this 
being due to intracranial pressure. There was no very great evidence 
of pressure or traction on the posterior spinal roots at any time. 
The tumor has the appearance of a multiple sarcomatosis but, while 
Dr. Friedman would lead you to believe that this was my diagnosis, 
the picture which you see in the base of the skull is not very near the 
picture which I had formed in my mind. My conception of the dis- 
ease was a tumor primarily of the base of the skull, and secondarily 
of the brain. If you will look at this specimen you will find that 
the lesion is one of sarcomatosis. Such conditions frequently affect 
the meninges. 



NEW YORK NEUROLOGICAL SOCIETY 305 

CASE OF INTERNAL COMMUNICABLE HYDROCEPH- 
ALUS BEARING UPON RECENT EXPERIMENTAL 

WORK 

[Dr. Strauss' Abstract of His Remarks] 

Dr. I. Strauss and Dr. J. H. Globus (latter by invitation). 
The case presented was that of a three months' old child which was 
admitted to the Pediatric Service of Mount Sinai Hospital. It was 
one of enlarged head and dimmed vision. The child had weighed 
six and a half pounds at birth, was breast fed for three weeks, and 
subsequently bottle fed. After birth the head became progressively 
enlarged. The- child had club feet, legs were held flexed and in 
contracture, the arms moved freely. Fluid was removed from the 
ventricles, and after the removal the fontanelles remained depressed. 
The child was apparently blind. 

The brain exhibited a marked degree of internal hydrocephalus. 
The cortex of both cerebral hemispheres was reduced to paper thick- 
ness. Pons, medulla and basal ganglia appeared normal in size. An 
India ink injection was made after death, in the ponto-cerebellar sys- 
tem, and the injection went forward as far as the chiasma and covered 
the cerebellum and the midbrain. None of the injected fluid reached 
the surface of the hemispheres, nor did it enter the ventricles. An 
examination of the meninges gives no evidence of an inflammatory 
process. It therefore appears that the obstruction in the subarachnoid 
space was a developmental defect. 

Sections through the midbrain also show a rudimentary remains 
of the aqueduct of Sylvius, so that this case was both an obstructive 
and communicable type of hyprocephalus. 



TERATOID CYST OF THE HYPOPHYSIS 

(Pathological Material and Lantern Slide) 

[Abstract by Dr. Globus] 

Dr. J. H. Globus and Dr. I. Strauss. The tumor presented 
showed, in addition to the uncommon histological structure, features 
of clinical significance. It occurred in a girl, six years of age, who 
had had no previous illness and had been quite normal up to the 
time of the onset of symptoms, six months before admission to the 
hospital. At that time she became restless, markedly constipated, 
lost her appetite and developed polydipsia and polyuria. Several 
weeks later, the diagnosis of diabetes was made, and the child was 
treated accordingly. The child was losing strength, and would fre- 
quently complain of fatigue; she gave up playing and became con- 
fined to bed because of constant headaches and general weakness. A 
week before admission it was noted that the child's mouth was drawn 
to one side and her left shoulder dropped and would frequently 



306 NEW YORK NEUROLOGICAL SOCIETY 

twitch. She was admitted to the hospital with the complaint of 
headache, fatigue, excessive thirst, enuresis, loss of appetite and 
weakness of left shoulder. 

Physical examination: Fairly well nourished child, somewhat 
undersized, with a profuse growth of laguno hair all over the body. 
There were found ptosis of the right eyelid, weakness of the right 
internal rectus, left pupil larger than the right, both pupils reacting 
to light and accommodation. There were also left facial weakness, 
slight weakness of the left arm and hand, and slight weakness of the 
left leg. The deep reflexes were more active on the left side, though 
generally reduced. Gait and station were normal. The abdominal 
reflexes could not be elicited. Spinal fluid was negative as regards 
cells and Wassermann reaction. The diagnosis of neoplasm involving 
the posterior lobe of the pituitary and the right crus cerebri was made. 

At the autopsy a large purple fluctuating mass was found at the 
base of the brain. It covered the optic chiasm and was adherent to 
the latter. Posteriorly it filled up the entire interpeduncular space. 
Its bulging inferior surface, which was partially free, was prolonged 
into a funnel-shaped process which seemed to be continuous with the 
pituitary body. The latter was small in size and compressed, and 
was lodged in a shallow and eroded sella turcica. The base of the 
superior surface of this mass was firmly implanted in the substance 
of the basal surface of the brain. It occupied the entire intra- 
peduncular space and, because of pressure on the adjacent structures, 
the optic chiasm and the optic tracts were flattened. The tuber 
cinereum and the mammillary bodies could not be identified since 
the floor of the third ventricle was stretched and flattened by the 
tumor mass which almost obliterated the cavity of the third ventricle 
by its protrusion into it. The cerebral peduncles were displaced 
laterally and, due to pressure, were reduced in size; this was more 
pronounced on the right side. The neoplasm, which contained a 
dark-brown, granular, semi-fluid mass, was a rather thin-walled cyst, 
lined by a corrugated membrane which was studded with numerous 
small, glistening elevations. Cholesterin crystals were present in the 
contents of the cyst. The cyst was four centimeters long, three and 
a half centimeters in width. It pressed upon and flattened both of 
the optic nerves and the right oculomotor. A horizontal, longti- 
tudinal section of the brain showed the cavity of the cyst fully 
exposed and that, at the left of the anterior portion, its wall was 
thickened, giving rise to a tuberous elevation cartilaginous in 
consistency and somewhat translucent in appearance. 

The wall of the cyst was for the most part uniform in thickness 
and showed a more or less uniform histological structure. It was 
composed of three layers. The innermost coat, a layer of stratified 
squamous epithelium, showed at a few points some little variation in 
the character and maturity of its epithelium. The middle layer con- 
sisted of loose connective tissue in which were imbedded numerous 
glandular acini and many small ducts. The glands appeared to be 
salivary in character and the ducts were lined by tall cuboidal epithe- 
lium and filled with a pink staining colloidal substance. The third 



NEW YORK NEUROLOGICAL SOCIETY 307 

and outermost layer was composed of a fairly thin stratum of dense 
fibrous connective tissues forming a boundary between the brain 
tissue and the cyst and serving as the outer protective wall of the 
exposed part of the cyst. 

The lining epithelium showed its strong resemblance to the epithe- 
lium of the dermis of a young embryo by its three-layered formation 
and by the presence of hair germs. Again accumulation of deeply 
staining epithelium cells in concentric layers gave rise to structures 
not unlike epithelial pearls. The cells in the center of these pearls 
appeared to undergo degeneration, the peripheral cells having 
retained the structure of basal-cell epithelium and showed, when 
stained specifically, the characteristic intercellular bridges and kerato- 
hyaline granules. In the small cartilaginous mass there were found 
several types of embryonic tissue of mesodermal origin such as 
embryonal cartilage mucous connective tissue, young fibrous tissue, 
newly formed bone with typical bone corpuscles, calcified trabeculi. 
endosteum and periosteum crowded with numerous osteoclasts, 
osteoblasts, osteophites, and marrow cells filled with yellow granules 
which on staining with specific methods gave a typical iron reaction. 
In addition to these structures, there was a collection of cells arranged 
in long cords and supported bv a fine reticulum; they contained fat, 
and in general strongly resembled cells in sebaceous glands. 

The unusual histological features of the tumor, place it among a 
rather small group of neoplasms, which recently, through the work of 
Erdheim, have been traced to misplaced embryonal remnants of the 
subinvoluted cranio-pharyngeal duct, though such cysts have been in 
the past variously described as cholesteatomata, dermoids, epider- 
moids and occasionally, because of the occurrence of cartilage and 
bone in their walls, as teratomata. 

• The confusion in the classification of such cystic neoplasms was 
due to the fact that some coincidental findings, such as cholesterin 
crystals, bone or cartilage, were accepted as basic and fundamental 
features of such tumors. 

It is most probable that the various tissues found in the neoplasm 
described were derived from the two germ layers, ectoderm and 
mesoderm, which go to make up the mature skin. It is then assumed 
that the cyst described is a teratoid growth, autochtonous in origin, 
which was formed by an embryonal misplacement of cells from the 
two germ layers during the period of the invagination of the ectoderm 
and in the course of formation of the hypophysis. 

The gross anatomical relations of the tumor to the hypophysis 
and to the structures in the floor of the third ventricle are of signifi- 
cance in view of the clinical manifestations pointing to a disturbance 
of pituitary functions. This is particularly true in the light of recent 
experimental works by Haily and Bremmer, who have shown that 
the clinical symptoms of diabetes insipidus, such as polydipsia, poly- 
uria and cachexia, can be provoked with certainty by a lesion pro- 
duced in the postinfundibular region of the hypothalamus, while the 
complete removal of the posterior lobe of the hypophysis does not 
lead to permanent production of such symptoms. 



308 NEW YORK NEUROLOGICAL SOCIETY 

The tuber cinereum and the mammillary bodies were, and, in fact, 
the entire floor of the third ventricle was almost completely destroyed 
through pressure by the tumor mass, while the infundibular portion 
of the hypophysis showed no change except compression. It would 
appear that the findings in this case serve to support the results of 
the experimental work of Baily and Bremmer. 



THE BIOLOGICAL INTERPRETATION OF 
PSYCHONEUROSIS 

[Author's Abstract] 

Dr. L. Grimberg. Every psychoneurotic, if carefully examined, 
shows some endocrine disturbances as evidences of endocrine mal- 
development. This endocrine condition is a prenatal state and forms 
an organic inferiority, which means that the individual in question 
is a vulnerable person and under certain circumstances will develop 
a psychoneurosis. The classification of psychoneurotics at present is 
done entirely from the psychological point of view. Even if the 
Freudian theory is accepted, the psychoneurotic is conceived as a 
result of a conflict going on in the individual in question, and the 
compensation which arises in the form of a psychoneurosis is a result 
of psychological maladjustment. On the other hand, an individual 
cannot be conceived as an entity. It is erroneous to look at him 
otherwise than as a sociological unit. His illness is defined not so 
much by his mental state as by his mental attitude. The psycho- 
neurosis is manifested by the relations between the individual and 
other individuals. It is exactly that point which has been over- 
looked in the study of psychoneurosis, and the importance of the 
milieu in the production of psychoneurosis must be considered if we 
intend to reach to a proper understanding. 

Based upon the theory of Weissman (on heredity) every normal 
individual is born with the potentiality to reach the stage in which 
his parents are and also with the potentiality to overreach that stage. 
(That determines progress.) That will explain the appearance of 
atavism, because there it is possible that the molecular structure of 
the germ cell may be so changed that regress is taking place. 

I will explain the nature of the conflict which takes place between 
the conservative elements transmitted by heredity — egotism — and the 
milieu. The milieu represents all that surrounds the individual. 
Sociologically it is the society. Society is formed by conscious ele- 
ments, but the resultant is not a conscious entity. On the other hand, 
this resultant of all the conscious elements — society — represents an 
equilibrium between the conservative factor transmitted by heredity 
(egotism) and the revolutionary factor (altruism). The normal 
individual is born with the potentiality to reach that compromise or 
equilibrium of the social entity from which he springs. 

A classification of the psychoneurosis, based upon the study of 
this conflict, will give us a more reasonable and plausible explanation 



XEir YORK NEUROLOGICAL SOCIETY 309 

of the appearance of psychoneurosis. Some of the classes of psycho- 
neurotics are as follows : 

(1) Individuals born without the potentiality of compromise. 
They are usually the amorals of Lombroso, the criminals and sexual 
perverts. 

(2) Individuals born with the potentiality of compromise but at 
the same time the milieu, which comes into conflict with them at the 
start, like the family, is not in compromise. The result is that ego- 
tism instead of shaping itself becomes more pronounced. Or, the 
individual is developed into a personality with an exaggerated ego 
like the only child, though with the potentiality, and though the milieu 
is in compromise, but due to various causes. 

(3) Individuals who at one time in a certain milieu were in 
compromise, but then came into a different milieu and the conflict 
started anew. As examples we have the racial psychoneuroses in 
our country. 

Discussion : Dr. Russell G. MacRobert : The paper is very inter- 
esting, very well thought out ; but I find myself stumbling over some 
parts of it. For instance, I would like to ask if Dr. Grimberg really 
considers that emotional stress or strain, such as fright, grief, worry 
and chagrin, is less important than the character of the glands of the 
individual in determining a psychoneurosis ? 

Dr. Foster Kennedy: Dr. Grimberg's subject embraces so wide 
a field it would not be possible to discuss it properly in so limited a 
time. He defines a psychoneurotic as being an individual in constant 
reaction with his milieu. I do not quite know what he means by the 
use of the word " reaction." If he means conflict with his milieu 
I can understand it; but reaction is not necessarily conflict. After 
all, the whole process of life is one of reaction to the milieu, and that 
is a perfectly normal situation, not at all the abnormal condition of 
emotion suggested by the use of the word psychoneurosis. Again, 
Dr. Grimberg said that egotism was unknown among the lower 
animals. In what sense did he use the word egotism in that remark ? 
Dr. L. Grimberg : I use the term egotism in the sense we use it 
in ethics. I mean conscious sacrifice. Of course there is such a 
thing as egotism among lower animals. About the other questions, 
I did not say definitely that the endocrines have any importance at all. 
I just made the remark that they might show an organic inferiority of 
the individual. About the reaction I expressed myself badly. I 
really did mean that the psychoneurotic is in a continuous state of 
conflict with his milieu. That is exactly what I meant. 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 

Regular Monthly Meeting, December 15, 1921 
James B. Ayer, M.D., President, in the Chair. 



INFLUENCE OF VISION ON NYSTAGMUS 

Dr. C. L. Woolsey. Isaac Jones has said, " The intimate rela- 
tion between the ear and the eye can be best appreciated when we 
realize that the ocular mechanism depends upon stimuli from the ear 
for precision of movement." The intimacy of this relation may be 
greater than anticipated if we note the inhibitory influence of vision 
over the outward manifestations of vestibular function. 

There has been a great deal of discussion since the time of 
Flourens (1828) in regard to the cause of the " compensatory move- 
ments " or " with nystagmus " during rotation. When a normal 
pigeon is rotated, head free, certain movements of the head are noted, 
i. e., the head seems to move slowly away from the direction of 
rotation, then quickly in the direction of rotation. These movements 
are called the "with nystagmus." Gruenberg (1907) thinks the 
compensatory movements may be due to the constantly changing 
view, but further states : " They may also be quite independent of 
visual impressions. One is therefore driven back to a re-examina- 
tion of the semicircular canal theory, or to search for some other 
percursory movements or acceleration." Together with Prof. Wills, 
he concludes that the " compensatory movements " are due to the 
spin which objects are subject to when rotated. Isaac Jones (1918) 
states, " During the turning is a vestibular pull of the eyes to the 
left, that is to say, a nystagmus toward the right " — when rotating to 
the right. Rizto (London, 1920) concurs in this belief, briefly 
summed up, " The semicircular canals produce the compensatory eye 
movements when the head is in motion." In performing a number 
of experiments on the vestibular apparatus of the pigeon, it was 
evident that the " with nystagmus " of head or eyes during rotation 
depended in frequency upon the rate of rotation, ranging from 1 to 12 
movements of head through 360 degrees. It was noted that the 
eyes did not enter into the movements per se, if the head was free to 
move, but if the head was stationary the eyes moved. It seemed 
probable that vision was partly responsible for these movements on 
account of the range from 1 to 12. Vestibular stimuli could hardly 
produce such a variation, consequently numerous methods were 
employed to overcome vision without destroying sight, but all proved 
unsatisfactory. Following a suggestion of Dr. Stanley Cobb, experi- 
mental amblyopia was attempted. This was best secured by injection 
of a saturated solution of ammonium sulphate into the retina, which 

[310] 



BOSTOX SOCIETY OF PSYCHIATRY AND NEUROLOGY 3" 

produced amblyopia without destruction of iris, allowing subsequent 
interpretation of nystagmus with ease. Jones states that it requires 
approximately ten rotations of the human to cause the " after nystag- 
mus." Ten rotations of the normal pigeon in ten seconds produced 
an " after nystagmus " lasting for 3.2 to 4.6 seconds. When a pigeon 
with experimental amblyopia is rotated head free one revolution in 
10 to 20 seconds, there was no compensatory movement or " with 
nystagmus " of either eyes or head, which seems to refute the idea 
that the " with nystagmus " was due to " vestibular stimuli." The 
contention may be raised that the rate of rotation was too slow to 
produce any movement of the endolymph, but this is erroneous, since 
the same pigeon with amblyopia, when rotated one revolution in 20 
seconds, developed no " with nystagmus," but an " after nystagmus " 
lasting for 5.0 to 6.1 seconds. When rotated one-half turn in ten 
seconds, ho " with nystagmus," but an " after nystagmus " lasting 
for 3.1 seconds. When rotated one-quarter turn, no "with nystag- 
mus " developed, but an " after nystagmus " of 2.0 seconds duration. 
When rotated 10 times in 10 seconds there was a " with nystagmus " 
and an " after nystagmus " lasting for 12.0 seconds. The " with 
nystagmus " was due to the head being pivoted and not able to keep 
up with the body, hence a twisting of the head away from the direc- 
tion of rotation. This " twist " disrupts the muscle balance, which 
is the stimuli that causes the correction and thereby producing the 
" with nystagmus." 

In conclusion : In the normal pigeon it requires at least five revo- 
lutions to produce any appreciable " after nystagmus," which is 
always accompanied by a with nystagmus." With experimental 
amblyopia only one-quarter of a turn in five seconds is required to 
produce an " after nystagmus " of two seconds duration, which is not 
preceded by a " with nystagmus," which when compared with the 
normal pigeon shows the profound influence of vision on nystagmus. 1 



PROGRESSIVE MUSCULAR DYSTROPHY IN MOTHER 
AND THREE CHILDREN 

Dr. H. B. Eaton. Looking through the literature of this type of 
disorder I find we are in about the same position regarding it as we 
were in 1886. The family shown is a particularly good illustration 
of the disease. The mother says that she first noticed her difficulty 
when she was 15 or 16 years old by a weakness of the arm which 
she attributed to falling out of a swing. The two oldest children, 
13 and 12, have noticed for four or five years that they were unable 
to do what their friends did. The second boy, for instance, couldn't 
play basketball. The little girl of 6 has no trace of the disease so 
far as I am able to find. In the woman the reflexes are gone. In 
the older boy there are no tendon reflexes, but in the other boy they 

1 \ Preliminary Report of Experiments being done on Vestibular Ap- 
paratus of the Pigeon in the Neuropathological Department of the Harvard 
Medical School. 



312 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 

are diminished but present. The boys react to Faradism but the 
mother does not. 

Discussion: Dr. F. J. Farnell. I have had under observation for 
the last six or seven years a family with dystrophy, a Jewish family 
of three boys and two girls. The oldest boy, 16 years old, has fully 
developed pseudo-muscular hypertrophy with an inability to get 
about. The second is a boy of 13 who is a full-fledged case and has 
to be carried to school. The third child is also a boy of 11 years and 
his disorder is fully developed. The fourth child is a girl of 8 who 
is quite well. The fifth child, a girl of 6 years, who is quite well. 
There is no evidence of this disorder in either side of the family. A 
rather interesting feature is the effect of sugars upon these cases. 
By feeding them a great deal of sugar and raising their tolerance 
they become more active, and the two boys who are able to get about 
seem to last longer at their play. The sugar content in the blood on 
a starvation diet is usually 90 mg. per 100 c.c of blood, which, I 
believe, is somewhat low. The tolerance stays up on the sugar diet. 
Whether this has any significance in the interpretation of the dis- 
order I really don't know. When the first boy came under my care 
about eight years ago I began to give him very large doses of pineal 
gland, and for a while he seemed to improve and hold his own. The 
only additional experience I have had with endocrine glandular sub- 
stance in relation to pseudo-muscular hypertrophy was a marked case 
of pseudo-hypertrophy which for five years has been under large 
doses of pineal gland, and the disorder today is no further advanced 
than it was five years ago. In this case also the blood chemistry in 
relation to the sugar metabolism showed the same picture as with 
these boys. The method which has been used in the feeding for the 
sugar tolerance is to give an ounce of honey preceding the induction 
by a blood sugar test, and then in one hour an examination for blood 
sugar again; also a third examination two hours after the honey is 
taken. In these cases the sugar content of the blood will remain up 
longer than normal. In a normal individual the tolerance will rise 
within the first hour and it will drop to approximately normal by the 
end of the second hour, which, as I understand, indicates a normal 
sugar retention. Should the sugar content in the blood remain up 
at the end of the second hour it is called a high sugar tolerance. 
These children to whom the sugar was given seemed to be more active 
and able to handle themselves better than at the time they were not 
taking the sugar. 

Dr. D. J. MacPherson. We have one boy of 12 with this con- 
dition which started when he was about 7 years old. He has an 
infantile sella. I gave him pituitary substance and could see no 
difference except for the effect it had on his headaches, which he had 
on an average of once every ten days or two weeks. Without sug- 
gestion on my part that it might influence the headache, his mother 
reported to me that his headaches had gone. In about six months he 
reported that he had had no headaches during that entire time. 
Aside from that there was no particular change in his condition. I 
used the whole pituitary. 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 313 

THE USE OF SODIUM CHLORIDE IN CONCUSSION OF 

THE BRAIN 

Presentation of Cases 

Dr. Hugo Mella. Many patients who have received blows on 
the head develop headache of an extremely persistent type — often 
this headache does not commence until anywhere from several hours 
to a week or two after the injury. These headaches are not relieved 
by the ordinary remedies nor can they always be considered as the 
result of malingering to aid the patient in obtaining compensation, as 
they often occur in those cases in which this problem is not involved. 

Venous congestion in the fundus of the eye, or even choken disc 
may be found, but ordinarily nothing abnormal is elicited on physical 
examination; all that we find is a history of headache coming on 
after the cranial injury. It being a well-known fact that severe 
concussion of the brain may cause an oedema of such a degree as to 
require decompression operations to save the vision, if not life, I have 
thought for some time that those patients who have only the headache 
might very well have an oedema of the brain of a moderate degree, 
and that if this fluid could be removed from the brain, and the cere- 
bral blood vessels be relieved of this pressure so as to re-establish 
a normal circulation, then the headache would disappear. 

In 1919, Weed of Baltimore reported, in the American Journal of 
Physiology, that the injection of a 30 per cent solution of sodium 
chloride or a saturated solution of sodium bicarbonate into the circu- 
latory system would reduce not only the cerebro-spinal fluid pressure 
but also brain bulk. This reduction of cerebro-spinal fluid pressure 
and brain bulk also results from the introduction of a hypertonic 
solution into the intestinal tract. It would not be practical to use 
the intravenous method in ambulatory cases, so, when the patients 
can tolerate it, I have them drink the salt in solution, as I believe that 
if a hypertonic solution will reduce brain bulk experimentally in the 
lower animals, it might relieve these cases of " mild " oedema of the 
brain. Should the patient be nauseated by the salt solution, I have 
the salt put up in capsules of one-half gramme each. Weed has found 
that the approximate dose is one gramme to every ten pounds of body 
weight, and has had enteric tablets of one gramme each made up 
and they are now on the market, but I have obtained results with 
both the solution and the capsules, as illustrated in the following 
cases : 

Case 1. Massachusetts General Hospital. S. L., age 20, male, 
white, single. Occupation, order clerk. April 16, 1921, four days 
ago, fell three feet from a freight elevator. Was not unconscious, 
had a slight dizziness for one day, then a frontal headache came on, 
not severe but constant. No ringing in ears. Patient has a small 
wound on back of head, clean, no swelling, no surrounding tenderness. 

Pupils equal, react to light and distance. No nystagmus, fundi 
essentially negative. Tongue protrudes in mid-line. Knee jerks and 
ankle jerks equal and active. Plantars normal. Prescribed sodium 
chloride l / 2 dr. in water t.i.d. 



314 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 

April 18, 1921. Feels better for about three hours after taking 
salt. Headache is relieved but returns gradually. Sodium 
chloride 1 dr. in water, q. 4h. April 20, 1921. No headache except 
a little after riding on street car on way to hospital. Advised to 
return to work. Sodium chloride 1 dr. t.i.d. for one week, then b.i.d. 
for one week. May 4, 1921. Improved. No headache, outdoor 
life. May 18, 1921. No headache, no nerve lesion. December 12. 
1921. Patient entirely well, no return of headache. 

Case II. Massachusetts General Hospital. R. M., age 14, white. 
Occupation, school. November 22, 1921. Fall from a team and 
struck on back of head and neck about two months ago. States that 
he was all " mixed up " and out of his head immediately after the 
accident, but rapidly cleared up. Two weeks later " went out of his 
head " and has been irrational ever since. Is now mentally retarded. 
Responds slowly to questions. Very deliberate in speech and move- 
ments. No convulsions. Complains of headache. Said to have 
been normal before accident. No external evidence of injury to 
skull or spine. X-ray of skull and spine negative. Slight venous 
congestions of fundi, no choked disc. Has diplopia but it is not 
constant. Half dr. sodium chloride (in capsules) q. 4h. day and night. 
November 23, 1921. Brighter, responds to questions very well. 
Says he has a dull headache but it ceases after taking salt. Sodium 
chloride ]/ 2 dr. t.i.d. gradually reducing in one week to once daily. 
November 29, 1921. No headache, talks freely. Fundi negative. 
Salt l / 2 dr. t.i.d. December 6. 1921. Improving, no headache, still 
a little slow in responding to questions. Continue salt l / 2 dr. in a. m. 
December 13, 1921. No headache. Discontinued salt. December 
15, 1921. No salt. Complains of numbness in head, responds poorly 
to questions and appears quite disturbed. 8.30 p. m. given salt by 
mouth. 9.30 quieted down slightly but still quite disturbed. Salt 
was discontinued too soon. 

Discussion: Dr. F. J. Farnell. Probably some of the members of 
this Society recall a case of oidiomycosis presented by me about three 
years ago. The patient showed lesions on his chest and spinal 
column. He was treated with potassium iodide. It required 400 
grains of potassium iodide a clay to keep his disease in check. The 
man finally got well and lived until about a year and a half ago, 
dying from pneumonia. His family physician emphatically said that 
the man did not have the oidiomycotic infection at the time of his 
death. The percentage of potassium iodide that the man was taking 
led me to feel that it might be possible to attack the problem in a 
different manner so that the next case coming under my observation 
was at the State Hospital. I made a solution of 25 per cent and gave 
him 200 c.c. intravenously. Within a few days the man improved 
and gradually recovered. He is perfectly well today and shows no 
evidence of his disease as far as known. At that time he had skin 
lesions as well as a cerebrospinal disorder. Last April a child was 
brought to me with this disease. I gave her a 10 per cent solution 
and all lesions subsided immediately. The use of hypertonic sodium 
iodide solution intravenously as applied in fungus disease naturally 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 315 

led me to feel that it might be used for other purposes, and for two 
years past I have been giving hypertonic sodium iodide intravenously 
to three types of cases. First, those of oidiomycosis, which are 
cleared up almost immediately. The second group are cases of the 
meningitic and meningovascularis forms of syphilis. These are 
treated with a 10 per cent solution of sodium iodide intravenously, 
followed by salvarsan. The third group is the hyperemic headache, 
not the headache due to a blow but that which occurs periodically, 
and which is so severe as to keep the patient in bed for two or three 
days, — the type which manifests complaints of an ocular type. A 
series of cases of hyperemic headaches have responded immediately 
to a 10 per cent solution of sodium iodide. The usual procedure is 
100 c.c. of a 10 per cent solution of sodium iodide intravenously every 
five days (made up fresh). 

Dr. W. J. Mixter. I am naturally very much interested in this 
subject from the surgical point of view. We tried the use of hyper- 
tonic salt solution intravenously in a small series of severe cranial 
injuries without much effect. They were all severe and some of 
them were complicated cases. My own feeling is that the main 
effect in the traumatic case as in any other type of case treated with 
hypertonic salt solution is on the cerebrospinal fluid, and that there 
is probably comparatively little effect on the brain. This work that 
Dr. Mella is doing should be followed out in a larger series of cases 
and in the more severe type of concussion, if possible, a type which 
is kept in the hospital. I feel that severe concussion is definitely a 
subject for hospitalization, and cases can probably be followed there 
better than in any other way. We must remember that there is a 
definite rebound after the use of hypertonic salt solution, and we 
must be careful that our rebound is not enough to give us increased 
symptoms. Looking back 15 or 20 years, we find that one of the 
prime requisites in the proper treatment of concussion in this hos- 
pital was the most active purgation by salts. That method was 
dropped about the time I was house officer as being empyrical and 
probably of no value. I doubt if it has been carried out at all during 
the last few years. I believe that such purging probably did the 
same thing as the salt solution. 

Dr. Donald Gregg. Hypertonic salt solution in the form of 
Epsom salts has been used by most of us for years with some success, 
possibly only transient, in three kinds of cases, — headache, acute alco- 
holism, and epilepsy. Perhaps, instead of lessening " auto-intoxica- 
tion " or some other unproven condition, we have been de-hydrating 
the central nervous system a bit. Possibly, also, the new treatment of 
epilepsy by starvation gets results by a similar physiological method. 

SPINAL FLUID IN MULTIPLE SCLEROSIS 

Dr. H. B. Foster. Dr. Foster gave a preliminary report on his 
laboratory work with the cerebrospinal fluid in multiple sclerosis. 
He said that the 38 cases had been selected with due caution. The 
fluids all presented a negative Wassermann test. The cell counts 
were from normal to a marked increase C50 per mm.). The total 



3i6 BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 

protein content, quantitatively determined by the Denis- Ayer method, 
was from normal to nearly three times normal. In a relatively small 
number of fluids was a globulin ring present with ammonium sul- 
phate. The colloidal gold solution test gave a curve in the so-called 
(misnamed) paretic zone in half of all the fluids. However, if only 
those cases showing a progressive activity, clinically, were grouped 
together, the percentage giving this zone curve was considerably 
higher. The sugar, non-protein nitrogen, urea, uric acid, creatinin, 
acetone-bodies and chloride content was well within the normal limit 
of range. Blood correlations were made performing the biochemical 
tests enumerated above and the results were all within normal limits 
with one exception. The blood Wassermanns were also negative. 
The noteworthy feature of the laboratory findings in cerebrospinal 
fluid from multiple sclerosis cases, then, is the seeming approach to a 
normal fluid with the colloidal gold solution curve being a frequently 
occurring exception. 

(The full report of this work was given before the Association for 
Research in Nervous and Mental Disease in New York, December 
28-29, 1921, and will later appear in the Archives of Neurology and 
Psychiatry.) 



BULLET WOUND OF BRAIN 

Dk. E. W. Taylor. The following case is reported because of 
the unusual sequence of events in its course, especially the relation 
of trauma to what appeared to be epilepsy, the relief of epileptiform 
attacks by operation and the subsequent production of a hemiplegia 
with partial hemianesthesia and possibly symptoms relating to the 
thalamus : 

The patient, a man of 32, stated that he was accidentally shot at 
the age of five, the bullet lodging in the brain somewhat near the 
surface. No operation was done, he made a good recovery, became 
a ship mechanic, was admitted to the army and worked in a ship 
yard. While at this work in November, 1916, he fell a distance of 
40 to 45 feet, was unconscious but not paralyzed. Thereafter he 
had severe headache, and in the latter part of the month in which he 
was injured an epileptiform attack with apparently definite loss of 
consciousness. These attacks increased greatly in frequency and 
finally led to operation which resulted in the removal of part of the 
bullet, but unfortunately with a resultant hemorrhage which destroyed 
a considerable portion of the parietal region of the brain on the right. 
From this developed a severe left hemiplegia, naturally without 
aphasia. The epileptiform attacks ceased and he has had no recur- 
rence, nor headache, in spite of the destruction of brain tissue follow- 
ing operation. He later developed a slight hemianesthesia and sud- 
den attacks of pain which pointed somewhat toward the thalamus. 
His condition has not materially improved in spite of assiduous 
treatment. 

Discussion: Dr. W. J. Mixter. This patient at operation showed 
a simple cyst, and about it the fragments of the bone, to which a 



BOSTON SOCIETY OF PSYCHIATRY AND NEUROLOGY 317 

considerable fragment of lead was firmly adherent. On loosening 
the indriven fragment of bone, which measured 3 or 4 cm., there was 
profuse bleeding from one of the arteries of the brain which had to 
be checked with a tie and packed. The result was paralysis, which 
he now shows. I think this shows very clearly how extremely little 
damage to the brain will cause a rather severe type of palsy. I had 
no idea that he would show left-sided paralysis when he came out of 
ether. It was impossible at the time of operation to remove the 
other fragment of lead, which is in place still. I think one of the 
interesting points in this case is the fact that he has had no epileptic 
attacks since operation. Whether they will recur or not is a problem. 

Dr. J. B. Ayer. To what were the epeliptic attacks due? 

Dr. W. J. Mixter. The attacks were probably due to the cyst 
and the indriven pieces of bone. 



Current Literature 



I. VISCERAL NEUROLOGY. 

1. VEGETATIVE NERVOUS SYSTEM. 

Spiller, William G-. The Oculopupillary Fibers of the Sympathetic 
System; Division of the First Thoracic Root in Man. [Amer- 
ican Journal of the Medical Sciences, March, 1920.] 
Some knowledge has been obtained regarding the position of the 
oculopupillary fibers of the sympathetic system in the cervical cord, 
medulla oblongata and pons, but scarcely anything is known of these 
fibers in their relation to higher parts of the brain. A case of hemi- 
plegia was observed by the author in which the Claude Bernard-Horner 
syndrome was present on the side of the hemiplegia. Experimental work 
of importance on the animal brain has been done by Karplus and Kreidl 
to determine the intracerebral position of the oculopupillary fibers which 
seems to have established a center for the oculopupillary function in the 
cerebral peduncle, but the position of the fibers above this region in the 
cerebrum is uncertain. Spiller has come to the conclusion that in man 
the oculopupillary fibers do not decussate, or at least in very slight degree, 
in the pons or below the pons in the medulla oblongata or cervical cord. 
In two cases of tubercle of one-half of the pons the oculopupillary symp- 
toms were on the side of the lesion, and he has repeatedly seen oculo- 
pupillary paralysis of the sympathetic on the side of the lesion resulting 
from occlusion of the posterior inferior cerebellar artery. This occlusion 
produces softening in the lateral part of the medulla oblongata. He 
describes a case of tumor of the cord in which it was necessary to divide 
the first thoracic root to remove the tumor, and oculopupillary paralysis 
occurred. The case gave the opportunity to determine the innervation 
of the first thoracic root in the upper limb. So far as he is able to deter- 
mine this is the first case in which the symptoms resulting from division 
of the first thoracic root alone in man is recorded. 

Kotzareff, A. Partial Resection of the Cervical Sympathetic 
Trunk for Unilateral Hyperhidrosis. [Schweizer Archiv f. 
Neurol, u. Psychiat., 1920, Vol. 6, No. 1, p. 171.] 

An operation on the sympathetic for hyperhidrosis is here described. 
The patient was a woman, 46 years of age. who for three years had 
suffered from excessive sweating on the right side of the face and neck 
and on the right shoulder, breast, and arm. The spells occurred spon- 

[3i8] 



VISCERAL NEUROLOGY 310 

taneously or as result of nervous irritation. Sometimes they persisted 
for an entire day and the patient was obliged to change her clothes six 
or eight times during the day. The disturbance had proved refractory 
to treatment. An interesting fact observed by the patient was that when 
she perspired there was as great dilatation of the right pupil as when 
her physician used atropine. During these seizures she was obliged to 
desist from work. When the patient came to the observation of the 
author the only abnormal feature found was a small protrusion at the 
right sterno-cleido-mastoid region in the middle of the anterior boundary 
of the muscle. There was no muscular atrophy of the superior members, 
nor other symptoms characteristic of an organic disease of the central or 
peripheral nervous systems. An operation was performed under local 
anesthesia. An incision was made parallel to the anterior border of the 
sterno-cleido-mastoid muscle, and when the place was reached where 
normally the paraganglion of Luschka is situated it was found that this 
element was absent. From 1 to 2 cm. of the trunk of the sympathetic 
was resected and the wound was closed. In eight days after the opera- 
tion the patient had perspired only for fifteen minutes. When pilocarpin 
was administered she perspired moderately over the entire body; atropin 
did not produce dilatation of the pupils. The patient left the hospital 
v. ith a lesion of the right cervical sympathetic presenting the syndrome 
of Claude-Bernard-Horner which is met with in inferior radicular paraly- 
sis of the brachialplexus and in certain lesions of the cerebral hemis- 
pheres. She was entirely cured of the hyperhidrosis, but retained a 
partial paralysis of the cervical sympathetic with contraction of pupils, 
drooping of the upper eyelid and narrowing of the palpebral slit. Four 
similar operations have been described since the first surgical experiment 
on the great cervical sympathetic by Alexander in 1889. and the author 
in 1917 made a partial resection of the superior sympathetic ganglia in 
an infant aged 7 months for multiple and voluminous angiomata with 
compression and irritation of the two superior cervical ganglia. [J.] 

Asher, L. Central Properties in Peripheral Nerves. [Schweizer 
Archiv f. Neurol, u. Psychiat.. 1920, Vol. 6. No. 1. p. 168] 

Summation is one of those qualities which are regarded as character- 
istic of the central nervous system, distinguishing the latter from the 
peripheral nerves. Making use of a new method the author of this 
paper instituted experiments to determine whether peripheral nerves d<> 
not also manifest phenomena which are of essentially the same nature 
as the summation in the central nervous system. By researches made in 
association with Dr. Tischhauser, he was able to prove the existence 
of the so-called simultaneous summation in peripheral nerves. For 
demonstration two separate points of a peripheral nerve were brought 
under the influence of excitants which were below the threshold of stimu- 
lation it separately applied. In the muscles belonging to the nerve. 
contractions set in showing that excitements of the nerve had taken 



320 CURRENT LITERATURE 

place. By means of appropriate variations of the conditions of the 
experiment it was possible to inhibit a stimulation above the reacting 
threshold (which was therefore effective) by a second stimulation below 
the threshold. This discovery furnishes another example of inhibition 
of the sort already known in the so-called Wedenski phenomenon, being 
an inhibition in a peripheral nerve which is wholly analagous with the 
sort encountered in the central nervous system. More important than 
the proof of the simultaneous summation that of the summation of 
successive stimuli, each one of which alone was below the reaction 
threshold. The weaker stimuli following at intervals when continued 
for some time gradually produced excitation, just as in the central 
nervous system. These phenomena of summation observed in the 
peripheral nervous system are qualitatively like those observed in the 
central nervous system. 

Stewart, F. W. The Development of the Cranial Sympathetic 
Ganglia in the Rat. [Tourn. Compar. Neurol., 1920, XXXI, 163 
(36 Figs.).] 

Summary: (1) Large numbers of cells of vagus origin reach the 
cardiac, intestinal, gastric, tracheal, oesophageal, and possibly the 
pharyngeal plexuses. 

(2) Cells of Glossopharyngeus origin give rise to certain small 
ganglia of the pharyngeal wall, the posterior third of the tongue, the 
tympanic plexus, and, in addition, to the otic ganglion. 

(3) The spheno-palatine ganglion is a ganglion belonging develop- 
mentally to the ramus palatinus VII (great superficial petrosal nerve). 

(4) The spheno-palatine and otic ganglia are therefore developed 
from cells migrating along these nerve trunks which, in the adult, carry 
preganglionic fibers to the ganglia. 

(5) Circumstantial evidence favors the interpretation that the sub- 
maxillary and sublingual ganglia, together with certain small ganglia of 
the anterior two-thirds of the tongue, are of facialis origin, the path of 
migration being the chorda tympani. 

(6) Neuroblasts giving rise to the ciliary ganglion reach the orbit 
by way of the ramus ophthalmicus V. 

(7) The ganglion cells of the nervus terminalis originate in a pro- 
liferation of cells of the olfactory sac. 

(8) Ganglion cells of the carotid plexus and its allied plexuses, 
together with a portion of the cells of the tympanic plexus, arise as 
extensions forward from the superior cervical sympathetic ganglion. 
[Leonard J. Kidd, London, England.] 

Parhon, J. The Cardio-respiratorv Correlation in Neuropathol- 
ogy. [L'Encephale, 1920, March, Vol. XV, p. 185.] 
Inspiration in breathing normally causes the formation of a virtual 
vacuum in the thorax and thus the depletion of the blood coming from 
the brain and of the venous blood generally is facilitated. Whenever the 



VISCERAL NEUROLOGY 321 

inspirations are not sufficiently complete, there is, beside the sensation 
of oppression, or need of air, passive venous congestion and, conse- 
quently, an augmentation of the intercranial pressure. This tension, the 
author thinks, may contribute to the explanation of certain pathological 
phenomena on the part of the nervous system, not only of the psychic 
disturbances in those suffering from cardiac but also many other nervous 
factors (from anoxemia, auto-intoxication, etc.), and among them, in 
some cases at least, fascicular tremors, certain sensation of neurasthenics, 
and migraines. In a patient observed by the author there could .be no 
doubt of the connection between the nervous phenomena and the cardio- 
respiratory disturbances. This was a case of a young man who was 
subject to fascicular tremors in various muscles of the body (quadriceps, 
masseter, orbicularis oris, biceps, etc.), which were at time of such 
force that they resembled veritable clonic spasms. The patient had 
manifested respiratory insufficiency from infancy, a sequel to bronchial 
pneumonia. The contractions and muscular spasms first made their 
appearance after an attack of scarlatina. Later at puberty he had suf- 
fered from a feeling of oppression in the head and from phobias and 
obsessions. The author calls attention to the fact that these psychic 
disturbances may stand in close relation with the respiratory disturbances 
or perhaps with cardio-respiratory affections. Evidences of this are the 
facts that they develop from a neurasthenic feeling of tension in the 
head; they evolve on an affective foundation of anxiety; they are fre- 
quent in individuals suffering from Basedow's disease in whom anxiety 
is a nearly constant symptom and in whom there is also often diminution 
of respiratory amplitude. The author believes that the muscular spasms 
were due to irritation of the motor cortical centers by congestion (per- 
haps by microscopic hemorrhages) and to the acidifying of the blood 
and fluids accompanying anoxemia. Later the patient developed extra- 
systoles which the author is of the opinion stood in close connection with 
the respiratory difficulties. Neither the contractions of the voluntary 
muscles nor the extrasystoles appeared when there was sufficient respira- 
tory amplitude. Psychic irritation caused the extrasystoles but with 
these psychic irritations there were also disturbances of respiration and 
of these the psychic excitement really seemed to be the conscious transla- 
tion. The author, who has long held that respiratory modifications play 
an important role in affective phenomena, as a further example of the 
relation between cardio-respiratory function and nervous states now cites 
migraine, which he considers due to intercranial hypertension and venous 
stasis. The therapeutic effects of menthol is explained by the fact that 
more ample respirations are reflexly produced by it. [J.] 

Naville, F., and Brtitsch. Hematology in Neurology. [Schweizer 
Archiv f. Neurol, u. Psychiat.. Vol. IV, No. 1. p. 88.] 
The authors call attention of neurologists to a cause of vascular and 

circulatory disturbances of the brain and medulla which is frequently 



322 CURRENT LITERATURE 

overlooked, the physician being inclined to ascribe such nervous symptoms, 
when their pathogenesis is obscure, to arteriosclerosis, hypertension, 
fatigue, syphilis, etc. A few years ago one of the writers had oppor- 
tunity to follow a certain number of difficult cases in which no satisfac- 
tory interpretation could be found for extensive vascular lesions and 
prolonged cerebral circulatory disturbances. Examination of the blood 
or the autopsy revealed manifest erythemia, and for this reason the 
authors are convinced that physicians should never neglect the examina- 
tion of .the spleen and bone marrow in disturbances of the brain circula- 
tion of obscure origin. The authors describe four cases where the ner- 
vous and mental symptoms found their explanation as a result of Vaquez's 
disease. Among the effects of this disease may be cortical miliary hemor- 
rhages which spread in a slow and insidious manner, thrombi of veins 
and arteries, pseudo-tumors of the brain, etc., manifesting themselves in 
a variety of psychic and nervous phenomena, headache, unconsciousness, 
palsies, epileptoid attacks, and many other symptoms and combinations of 
symptoms which the clinician would find hard to explain in any other 
way. [J.] 

Landwehr, J. H. Colic from Acute Angioneurotic Edema (Quincke >. 
[Ned. Tijdschr. v. Geneeskunde. Vol. XII, No. 17. 1919.] 

On August 28, 1919, Mrs. B. came to me at my consulting hours with 
the following complaints : 

For some weeks past she had suffered in various places of the body 
from transitory swellings, which were neither painful nor itching, but 
were accompanied by an unpleasant feeling of tension. A peculiar feel- 
ing of itching and burning preceded the swellings. As a rule the symp- 
toms had disappeared after about half an hour; sometimes, however, 
the swellings continued for some hours. Usually they occurred on eye- 
lids, lips and chin, sometimes on arms, hands and feet. For the rest the 
patient felt quite normal. From the family anamnesis it appeared that 
her mother suffered from attacks of megrim, a sister from gall swellings. 

As on examination of the slightly nervous lady I did not find any 
deviations, I requested her to call again when such a swelling had come 
again. Some days later she came back with a swelling which covered 
about the whole chin. This swelling had the color of the surrounding 
skin, was not warm to the touch, was not painful when pressed, and 
elastic; finger-pressures did not remain visible. 

Later on I had once more an opportunity to see the patient when on 
upper and lower lip swellings were visible, which showed the same char- 
acteristics as described above. On account of their short duration and 
their great number, their recurrence, the absence of redness and itching, 
and also of burning (characteristics of ulticaria), the elastic substance 
of the swellings, which where they occur cause an unpleasant feeling of 
tension, it seemed to me most probable that this woman suffered from 
remittent acute edema, first described by Quincke. 



VISCERAL NEUROLOGY 323 

Some days later I was called in, because the patient was lying abed 
with serious pains in the stomach. I found her writhing with pain, like 
one who has an attack of colic. The pain was located in the region of 
stomach and liver, spreading thence to the back. On examination the 
whole liver-region proved painful when pressed, likewise the pressure- 
point of Boas, which extends at about the two lower breast-vertebrae, 
one inch to the right of the vertebral-column. By one administration of 
morphia (5 mgr.) and warm swathings the attack was got under; after- 
wards the patient felt very limp and faint. That very evening another 
edematic swelling appeared under one of the eyelids. The following day 
she had a grayish-white stool and the urine contained many gall-chromae. 
No jaundice followed. Next to the swellings of the skin it is those of 
the mucous membranes which are prominent in the disease described by 
Quincke. Collins 1 found the respiratory organs affected in 21 per cent 
of the cases. Cases have been described in which the swelling affected 
the cheek-membrane, the tongue, the tonsils, the uvula, even the whole 
pharynx. Most important indeed is the swelling of the introitus laryngis. 
which gives rise to very alarming symptoms, in which case only imme- 
diate tracheotomy can often save the patient from certain death. Some 
( Schlesinger, Solis Cohen. Halstedt) also believe the asthma nervosum 
to be affected by the symptoms described by Quincke. Besides the swell- 
ings in the region of the respiratory organs, cases have also been described 
of intermittently occurring symptoms in stomach and intestines. In cases 
of a mild type they are confined to a more or less severe pain in the 
stomach-region, together with a feeling of tension. Later on it may be 
followed by nausea. Striibing - describes a case which showed the symp- 
toms of tabetic crises, viz.. violent pains in the stomach-region together 
with nausea. Besides the stomach-complaints we often see intestinal 
disorder, colicky pains, shooting-pains and excessive diarrhea. Halstedt. 
Morris and Solis Cohen diagnosed intestinal bleeding accompanying 
attacks 

Tn a case described by Morris 3 , a piece of the mucous membrane of 
the stomach, which was strongly edematic. was found when the stomach 
was probed. 

Tn the course of the disease described above, we see that a sufferer 
from acute recurrent edema has an attack resembling bilious colic. This 
attack (since that time she has had a relapse) about simultaneously with 
the manifold, repeatedly returning swellings of the skin, in a woman 
absolutely healthy before, is too remarkable to surmise an accidental co- 
existence of various diseases, the more so as the nature of the symptoms 
may be readily explained by assuming an acute swelling of the mucous 
membrane of the gall-ducts. This hinders the discharge of the gall : 
owing to the obstruction in the gall-bladder, the dilatation of the inner 

1 Am. Jour, of Med. Sciences. 1892, Vol. 104. 

-Zeitschrift f. klin. Medis.. 1885. IX. 

! Am. Journal of the Med. Asso.. Nov. 1904. 



324 CURRENT LITERATURE 

coat of this organ so rich in nerves, and perhaps a reflexive contraction 
ot the sphincters of the gall-ducts, the symptoms of colic are called forth. 
About the pathology of the Edema of Quincke researchers still dis- 
agree. While some look it to be a disturbance in the circulation of the 
blood, others believe that in many cases poisonous matters affect the 
production of lymph, either by active cooperation of the nucleated epi- 
thelial cells of the capillaries, and in consequence of this increased secre- 
tion of lymph, or by increased transmission of the tissue-cells. That 
often also the nervous system plays a very important part may appear 
from the existence of transitory edemae in nervous individuals, often 
under psychical influence. The medicines recommended are: regulation 
ot the intestinal functions, lactovegetabilic diet, and, moreover, arsenic, 
strychnine and quinine. In the literature which was at my disposal, I did 
not find anywhere in the description of the internal symptoms of acute 
edema a case of swelling of the mucous membrane of the gall-ducts, in 
consequence of which the symptoms of colic arose. Therefore I thought 
it sufficiently important to give a brief report. [Author's abstract.] 

Rolleston, J. D. Persistent Congenital Oedema of the Legs (Mil- 
roy's Disease) in Mother and Daughter. [Review of Neurology 
and Psychiatry, Vol. 15, p. 480.] 

Familiar cases of this disease are extremely rare. In this instance 
the mother stated that besides herself and daughter, her mother and her 
mother's sister were similarly affected. Her two other children were not 
affected. No obvious cause for the oedema was discovered. The two 
cases presented the four cardinal symptoms of the condition described by 
Milroy in 1892: (1) congenital character; (2) limitation of the oedema 
to the lower limbs; (3) persistence of the oedema; (4) entire absence 
of constitutional symptoms. A special feature in both cases was the 
unilateral predominance of the oedema, the right leg in the mother, and 
the left leg in the daughter being chiefly affected. In addition to Milroy's 
original cases (nineteen cases in six generations ). the only other examples 
of congenital and hereditary persistent oedema of the limbs in literature 
are those of Nonne (eight individuals affected with congenital elephan- 
tiasis in three generations) and Lortat-Jacob (congenital oedema of feet 
in three generations). Their pedigrees will be found in Dr. William 
Bulloch's article on chronic hereditary trophoedema, together with the 
pedigrees of other cases in which the oedema was hereditary but not 
congenital. As none of the recorded cases has come to autopsy, the 
pathogeny of the condition remains obscure. Various hypotheses have 
been put forward, such as congenital malformation of the trophic centers 
in the spinal cord for the cellular tissue (Meige), abnormal development 
of the mesoblast (Rapin), affection of the spinal centers for the lymph 
secretion (Valobra), insufficiency of the thyroid or thymus (Spiller), 
and endocrino-sympathetic dystrophy (Ayala). [Atwood.] 



VISCERAL NEUROLOGY 325 

Andre-Thomas. Encephalic Perspiration and Spinal Perspiration. 
[L'Encephale, 1920, April, Vol. XV, p. 233.] 

Two periods may be distinguished in the clinical evolution of wounds 
of the cord. During the first, called by most writers the period of shock 
or inhibition, there is complete paralysis of all parts innervated by the 
segments of the cord below the lesion. The sweat secretions are almost 
entirely absent in this region, appearing only on the areas belonging to 
that part of the cord which has preserved connection with the brain. 
The secretion in these areas thus offers a means for determining the 
level of the lesion, and is called by the author encephalic perspiration. 
Later a phase occurs in which activity is manifested in the section below 
the wound, which, though cut off from the brain, comes under the inde- 
pendent control of stimuli from the periphery, resulting in pilomotor 
reflexes, sweat reflexes, etc. From clinical observation of his cases fol- 
lowed by autopsy the author comes to the following conclusions concern- 
ing the localization of the spinal sudorific centers ; these spinal wounds 
show that the sudorific fibers reaching a cutaneous territory belong to 
much lower segments than do the sensory fibers of the same area. There 
are perspiration centers for the head and neck and the upper part of the 
thorax to the third and fourth rib in that part of the sympathetic column 
which extends from the eighth cervical segment to the third dorsal. 
There are centers for the upper extremities in dorsal segments 5, 6, and 
7, but they probably extend also somewhat lower also. The author was 
unable to determine from his observations just how much, but probably 
not far beyond the eighth dorsal. It is very likely that there are no 
perspiration centers situated below the third lumbar segment. In para- 
plegics wounded in war the sudorific reflexes behave in a manner very 
similar to the pilomotor reflexes, which is very natural, as their centers 
are situated near each other in the spine. When the spinal perspiration 
predominates on one side, the pilomotor reflexes are more likely on the 
same side, but the study of the pilomotor reflexes gives more precise and 
trustworthy results concerning the condition of the spinal sympathetic 
centers than does the study of the sudorific reflexes. Even after the 
spinal perspiration, together with the defense reflexes, has once made its 
appearance in the region below the lesion, the sudorific secretion may 
cease again and the perspiration above and below the lesion may alter- 
nately recur and disappear. In some cases this phenomena may be 
referred to a diminution of urinary secretions (in one case the autopsy 
revealed that the kidneys contained phosphatic calculi), or to vascular 
tension, but it is always evident that the two sections of the sympathetic 
column — the one above and the one below the lesion — do not react in the 
same manner when under the same influences (elements secreted by the 
urine). The encephalic perspiration of the uninjured part of the body 
remains always under the control of the brain — a circumstance which is 
evidence of the existence of one or several sudorific centers in the 



326 CURRENT LITERATURE 

encephalon. The author's observations, therefore, seem to explain the 
physiological mechanism of the sudorific secretion, showing that probably 
certain conditions of the fluids of the body influence the secretion by 
their action on centers situated above the spinal cord; and thus the 
anatomo-clinical experiences are brought into accord with the views 
expressed by physiologists. [J.] 

Simons, A. Bone and Nerve. [Zeitschr. f. d. ges. Neurol, u. Psychiat., 
Vol. XXXVII, p. 36.] 

From the author's observation of a series of cases he found that as 
result of purely psychogenic paralysis and contractions a destruction of 
bone ensued. This destruction was sometimes simply indicated, some- 
times slight, but in some cases profound ; it involved one bone or several. 
After complete recovery normal bone structure may develop again. The 
localization and degree of the changes did not correspond to the sensory 
nerve supply to the bone, nor to the vasomotor disturbances, to the swell- 
ing of the tissue, nor to the ohysiological disturbances of sensibility, and 
the destruction is not a constant occurrence. Neither long continued pas- 
sive exercise nor massage seem to have any influence on it. Of twelve 
patients with psychogenic disturbances observed by the author eight were 
affected with bone atrophy. Of these, two, however, had suffered slight 
bone injury. One had received a wound in the lower third of the tibia 
which had healed rapidly without plaster cast; eight weeks after the 
injury a club-foot developed under psychogenic influences. The other 
patient had sustained a slight oblique fracture of the ulna at its upper 
part which the Roentgen picture showed had healed successfully. If the 
psychogenic influences had not supervened the hand could have been used 
shortly after the injury and the foot of the first patient two or three 
weeks after the injury. The degeneration of bone was much more 
profound on the foot than on the hand. This is explicable by the 
relatively greater rigidity of the foot and the greater susceptibility of 
these bones to functional disturbances. The author is of the opinion 
that in his two cases the bone atrophy cannot be entirely referred to the 
continued rigidity of the limbs. The influences of wounds of this sort 
are more profound than becomes apparent clinically, as is the case in 
those relatively slight skull wounds which after years cause serious 
mental disturbances; the bone atrophy primarily due to a deep-seated 
injury could not get better because of the psychogenic rigidity of the 
limbs. But in the remaining cases there were no injuries to the bone, 
and no other influence which could alter the bone structure was active. 
Here the atrophy is wholly of internal origin. Nonne called attention 
to the fact that the normal bone findings in many cases of hysteria after 
prolonged ab.sence of sensory and motor function furnish strong argu- 
ment against the inactivity as cause of the atrophy, and the author 
raises the question in connection with his present observations whether 



IISCERAL NEUROLOGY 327 

there is not a neurotic (reflex) bone atrophy entirely distinct from the 
atrophy due to inactivity. Nonne's more recent observations, together 
with the author's, point to a bone destruction of this nature. [J.] 

Schuster, Paul. Cutaneous Nevi and Nervous Diseases. [Neuro- 
logisches Centralbl., Vol. XXXVIII, No. 8, p. 258.] 
There is little information in the literature as to whether or not 
cutaneous nevi occur with special frequency in any definite disease group. 
Michel alone has given statistical data on the subject. From a material 
of 1,000 he found that 99 per cent of individuals over 10 years of age 
have cutaneous nevi. but the author points out that Michel's results, 
obtained from patients in hospitals, were not based on average individuals 
and were not therefore evidence of the conditions generally prevailing. 
In the total of individuals observed in recent years by the author (exact 
number unknown), including a large number of otherwise healthy indi- 
viduals with peripheral wounds received in the field, all of whom were 
examined for nevi, 85 were selected because of the extraordinarily large 
number of these cutaneous signs found on their bodies. These were all 
neuropathic individuals or those with somatic defects of development, 
thus showing an unmistakable affinity of the nevi for endogenous nervous 
disease. The family anamnesis of these patients also revealed frequent 
examples of remarkably numerous cutaneous nevi in the relatives. These 
cutaneous phenomena varied from light brown or darker colored spots to 
small wart-like growths in most cases preserving considerable uniformity, 
but sometimes angiomas or skin fibromas were combined with the other 
more usual types. The formations were variously localized, but the 
author emphasizes that they never follow the course of the peripheral 
nerves and that it was impossible to establish any connection between the 
distribution and the spinal cord. The greatest number of nevi were found 
on a neurotic (innumerable) : a paranoiac had 74; one constitutional 
neurasthenic 47; another 45. Dermatologists are now unanimously of 
the opinion that only the tendency to nevi formations is congenital and 
that the formations themselves appear later in life, and the author 
believes that a relation exists between these cutaneous affections and 
the constitutional moments which lead to nervous disease. [J.] 

Dwyer, H. L. Chondrodysplasia: Multiple Cartii. acinous Exos- 
toses. [Am. Jour, of Dis. of Children, Vol. XIX, No. 3. March. 
. 1920, pp. 189-200.] 
Four patients presenting multiple cartilaginous exostoses are described, 
and the literature on the subject reviewed. In three of the patients, 
a man and his two children, the growths were causing no disturbance 
and the patients were aware of only a few of the most prominent ones 
on the extremities. The fourth patient, a boy of 12, came from a family 
in which several members were similarly affected. Small growths were 



328 CURRENT LITERATURE 

noticed in infancy, and these increased in size until it was necessary to 
remove some of them at 6 years of age, and again at 12. Those giving 
the most trouble were on the ventral surface of the great toe, the anterior 
surface of the radius, the inner side of the femur and in the popliteal 
space. The largest growth removed was about two-thirds the size of a 
lemon. Radiographic examination showed a bilateral arrangement of 
osteo-chondromata on the various long bones, near the epiphyseal lines, 
the shaft being comparatively free. The larger growths tended toward 
spur formation, the spur always pointing away from the nearest joint. 
Microscopically, the growths were found to be covered with a thickened 
periosteum containing isolated deposits of cartilage cells. In the cases 
described in the literature these isolated nests of aberrant cartilage cells 
within and beneath the periosteum, and in places where cartilage does not 
exist normally, is a characteristic feature, and is evidence that the 
condition is a chondrodysplasia, and not a simple hypertrophy of pre- 
existing cartilage. The condition is usually associated with deformities 
of the skeleton such as shortening, curving and thickening of the long 
bones. It affects only the bones of intra-cartilaginous origin. Associ- 
ated neurologic manifestations that have been noted are ulnar and radial 
nerve -paralysis, cord lesions from endostoses, muscular dystrophy, and in 
one case acromegalic symptoms from a growth in the sella turcica. 
Injuries to blood vessels have been reported, principally trauma and 
aneurysm of the popliteal artery. The hereditary feature is well estab- 
lished; the disease can be transmitted by an apparently unaffected female, 
but there is no good evidence that the unaffected male can transmit the 
disease. Microscopically the condition has much in common with Chon- 
dystrophy (Achondroplasia), and it is suggested that a close relationship 
exists between them. The disease is a well-defined clinical entity and, 
judging from the case reports of the past few years, it is by no means 
rare. [Author's abstract.] 

Marinesco, Gr. The Temperature of Skeletal Muscles. [Compt. 
Rend. Soc. de Biol., 1919, LXXXII, May 31, p. 561.] 
Although the temperature of the skeletal muscles of animals and man 
has been tested by means of thermo-electric needles, but little attention 
has been paid to the temperature of the muscles in neuropathological con- 
ditions. Marinesco has done this in many diseases of the nervous sys- 
tem by means of the apparatus of Mdlle. Grunspan. In organic 
hemiplegia there is a lowering of temperature in the muscles of the 
paralyzed side, the degree of which is dependent on the duration of the 
affection and on the degree of contracture: it is greatest in the distal 
parts of the limbs. Hypothermia of the muscles is also present usually 
in cases of paralysis agitans, sometimes to an even greater degree than 
in hemiplegia, both in cases with or without tremor : the temperature of 
the thenar muscles may be as low as 25° C. Apparently the presence of 



VISCERAL NEUROLOGY 329 

tremor tends to keep up the temperature of a muscle to some extent. 
Hypothermia of the muscles is present also in cerebral diplegia, tabes 
dorsalis, Friedreich's disease, myopathies, and in Thomsen's disease. 
The paper has some theoretical remarks, and the question of the 
temperature of muscles during regeneration after nerve suture is 
considered. [Leonard J. Kidd.] 

Campbell, Alfred W. A Case for Diagnosis (Thomsen's Disease). 

[Med. J'nal of Australia, Sydney, Dec. 13, 1919.] 

In summary, this case concerned a man, 27 years of age, who for 
ten or eleven years had shown apparently remarkable muscular develop- 
ment (Herculean type), but whose real muscular power was slight and 
subject to easy fatigue, whose every movement was impeded by " inten- 
tion rigidity " and tendency to tonic contraction, and whose muscles 
showed the myotonic electrical reaction of Erb. In these respects the 
clinical picture fitted Thomsen's disease. It was incomplete, however, 
inasmuch as the marks both of familial and congenital origin were want- 
ing (knowledge of the family history did not go beyond the present 
generation) ; also, that slow, tonic contraction of the muscle, to be 
induced by percussion, said to be characteristic of Thomsen's disease, was 
not demonstrable. In this connection it was indicated that, judging from 
other reports, cases varied greatly from the original form as described 
ty Thomsen, and it was suggested that possibly the muscular reaction in 
question was present only in the ingravescent stage of the disease. A 
biopsy and microscopic examination of an excised portion of the biceps 
branchii muscle proved disappointingly negative. Changes reported by 
other writers, scattered hypertrophy of muscle fibers, increase of sarco- 
lcmma nuclei and permeation of the sarcoplasma with granules (Schieffer- 
decker), were not present. 

Discussing the pathology of Thomsen's disease the writer thought that 
the character of the disease suggested a nervous more than a primary 
muscular origin, that might be in cerebral motor cortex, only to be dis- 
closed by exhaustive examination, or in some synapse, for example, 
where nerve is switched on to muscle, or lastly, if there be truth in the 
hypothesis that striated muscle has a dual innervation, the twitch element 
being supplied by medullated fibers, the sluggish by non-medullated, then 
search is to be made in the non-medullated system, because the victim of 
Thomsen's disease is emphatically wanting in the twitch element. 
[Author's abstract.] 

Pulay, Edwin. Myasthenia Gravis with Autopsy. [Neurol. Cen- 
tralbl., Vol. XXXVIII, p. 263.] 

The author communicates a well-characterized case of asthenic bulbar 
paralysis. The case was that of a girl, 17 years of age, who developed 
the usual myasthenic symptom complex, with the exception that here, 



330 CURRENT LITERATURE 

as in one of Curschmann's cases, disturbances of the bladder made their 
appearance in the earliest stages of the disease. The section revealed 
enlargement of the thyroid (a goiter), status thymico-lymphaticus-hypo- 
plasticus, narrowing of the larger vessels, hypoplasia of the genitals, 
large spleen and accessory spleen. The pathologico-histological exam- 
ination revealed no change in the central nervous system nor in the 
muscles except an accumulation of fat globules by the Marchi methods, 
to which Marburg has called attention. Reviewing the autopsy findings 
in the endeavor to throw light on the still obscure problem of the etiology 
of myasthenia, the author notes that, notwithstanding the presence of a 
goiter, no combined effects of thyroid and thymus could be established 
the correlation of which in producing this disease is defended by Mark- 
elow and Tobias among others; though there was a slight hyperfunction 
of the parathyroids the author does not see therein, with Lundborg and 
Chvostek, the essential etiological moment of the disease, but considers 
rather the condition of the thymus as part evidence of an abnormal con- 
stitution which would find expression in dysfunction of all the glands, 
hut the dysfunction of the glands could not be regarded as the essential 
cause of the myasthenia, however, because there is pluriglandular dis- 
turbance in many cases there are no signs of myasthenia. Morris 
Erande's view that myasthenia is a neurogenic disease is also not con- 
firmed by the anatomical findings in the author's case. Pemberton dis- 
covered increased secretion of calcium in this disease. The author is of 
the opinion that only a combination of all these factors furnishes an 
adequate etiological explanation of myasthenia. The abnormal constitu- 
tion, as it were, sensitizes the endocrine glands, disturbing, not the func- 
tion of a single gland, but of all of them, which is expressed in disturb- 
ances of the vegetative nervous system, producing the various neurogenic 
disturbances. The reason for the affection of the muscular system is 
found in a predisposing inferiority which in turn stands in connection 
with the abnormalities of calcium metabolism. In some cases of degen- 
erative endocrine disturbances affecting the vegetative nervous system 
and standing in relation to disturbances of metabolism, it is the skin 
which is affected, in others the nervous system and in myasthenia it is 
the muscles which offer the locus minoris resistentiae. [J.] 

Ruben, Martha. Myotonia Atrophica (Dystrophia Myotonia) with 
Remarkable Gibbus Formation. [Neurol. Centralbl.. Vol. 
XXXVIII, p. 149 and p. 185.] 

The case described is of a pronounced Steinert type, differing from 
previously published cases only in the circumstance that the long muscles 
of the back were affected with resulting formation of a very prominent 
gibbus extending along the spine, a phenomenon which may be regarded 
as an intensification of the symptoms belonging to this group but in no 
way as falling outside of the disease picture. While nearly all recent 



VISCERAL NEUROLOGY 33i 

writers regard this disease as a separate entity, Higier sees in it an 
aggravation of Thomsen's disease — unwarrantedly in the opinion of 
the writer, because myotonia atrophica, beside having a group of symp- 
toms peculiar to itself (disappearance of fat, baldness, cataract, vasomotor 
;ind inner secretory disturbances, absence of tendon reflexes, ataxia, 
atrophy of testicles, etc.), is, in contrast with Thomsen's disease, always 
acquired, always follows a stereotyped form in regard to the muscle 
groups attacked, is always progressive, and is rarely familial. Though 
the pathological material offered for the study of this disease is astonish- 
ingly limited, the following conclusions may be drawn concerning the 
etiology: infections may be excluded as cause; myotonia atrophica is 
not a myogenic disease; for, though the myogenic explanations account 
for particular phenomena, as may also the factor of inner secretory dis- 
turbances, neither explanation accounts for the entire disease picture. 
Trauma seems sometimes to be an activating moment which determines 
the open manifestation of the disease. Congenital inferiority may be 
responsible for the disease but not inferiority of the muscular system 
alone. A congenital inferiority of the central nervous system is in no 
way excluded (Stocker believes myotonis to be due to degenerations of 
regions in the brain connected with those to which Parkinson's and 
Wilson's disease are due. i.e.,' in the basal ganglia). Erb's assumption of 
a trophic neurosis of the muscles from disturbances in the central trophic 
apparatus is in contradiction with no other experiences and they may 
all be combined under this conception or subordinated to it. [J.] 



Moll, J. M. PSEUDO-HYPERTROPIIIC MUSCULAR DYSTROPHY IN AN 

African Native. [Med. Journ. of South Africa, Oct., 1919, p. 60.] 

The author records a case of pseudo-hypertrophic muscular dystrophy 
in a male native of Shangaan, which is noteworthy in several respects. 
The patient is 18 years old. His history was scanty: he seems to have 
been ill three or four years previously, and then he improved, but within 
the last few months he has become worse again. He is a typical case 
of the disease, with lordosis, affection of gait, loose shoulders, and wing- 
ing of scapulae, with weak muscles of the pelvic girdle. The hyper- 
trophied muscles are firm and tough to the touch. He has loss .of arm 
and knee jerks. Wassermann is negative in the blood serum. But the 
cerebrospinal fluid gave a weakly positive Wassermann, though there 
were neither cells nor globulin. The blood picture showed a slight 
excess of uni-nuclears (32 per cent). This peculiarity was found by 
Levin in several cases of the disease. Treatment witli antispecifics, 
injections of iodolysin, and glandular extracts did no good. Moll has 
seen a few cases of this disease in white children in South Africa, but 
never over 12 years of age. He gives three illustrations of his case. 
[Leonard J. Kidd.] 



332 CURRENT LITERATURE 

Neumark, S. Myokimia and Muscular Changes in Scleroderma. 

[Schweizer Archiv f. Neurol, u. Psychiat., 1920, Vol. VI, No. 1, 

p. 125.] 

The author reviews the cases of myokimia which have been described 
since Schultze, in 1895, first called attention to this disease. Very dif- 
ferent disease pictures have been gathered together under this name, and 
a whole series of diseases has been called myokimia which are only symp- 
toms of other diseases of the nerves or of the medulla oblongata. The 
author differentiates symptomatic myokimia from essential myokimia, 
stating that in a pathological sense the two forms may be distinguished 
from each other as follows : in essential myokimia it may be assumed 
that there is no somatic change in the nervous system and that the 
phenomena may be regarded as exclusively an expression of a neurosis; 
symptomatic myokimia. on the contrary, may be referred to an organic 
lesion in the peripheral neurons. The author describes a case observed 
by him, which he places in the group designated essential myokimia. 
Instances of this type are very rare and the author's case is further inter- 
esting from the fact that it was associated with scleroderma. In dis- 
cussing the etiology the author states that pure functional disturbances in 
the nervous apparatus of the vessels may condition permanent changes. 
A prolonged pathological activity of the vasoconstrictors and vasodilators 
must necessarily induce disturbances of nutrition in the walls of the 
vessels, and thus give rise to degenerative and proliferative processes. 
In those diseases which are characterized by vasomotor disturbances, 
such as Raynaud's disease and scleroderma, the vessels are very fre- 
quently diseased. The activity of the vessel nerves is regulated reflexly 
by those nerve fibers which are conductors of sensibility. If the sensible 
vasomotor reflexes are disturbed, either through irritation or destruction 
of the vasomotor centers in the medulla oblongata, trophic disturbances 
in the tissue may result such as occur in syringomyelia, for instance. It 
is noteworthy that syringomyelia often occurs in connection with Ray- 
naud's disease and scleroderma, and it is very probable that the muscle 
changes in scleroderma are due to purely vasomotor disturbances, and 
that they may therefore be referred to disease of the small muscle vessels, 
or in cases where these are not present, directly to disturbances of the 
vessel innervation. The author states that it is highly improbable that the 
myokimia in his case was conditioned by a disease of the face muscles, 
because there was no atrophy nor sclerosis of the muscles, because the 
vasomotor disturbances existed only in the hands and upper thigh and 
not in the face, and because fibrillar and fascicular twitchings in the 
progress of muscular changes are very rarely observed. An evidence of 
the purely functional origin of the twitchings was the fact that they 
vanished during sleep. This coincidence of scleroderma with myokimia 
finds satisfactory explanation, according to the author, in the assumption 
that they are both different manifestations of one and the same general 
neurosis. [J.] 



VISCERAL NEUROLOGY 333 

I inkelnburgh, Rudolf. Nervous Disturbances of the Vessels of the 
Heart as a Cause of Arteriosclerosis. [Deutsche Zeitschr. f. 
Nervenh.. Vol. LX, p. 90.] 

Concerning the origin of arteriosclerosis there is diversity of opinion, 
some writers regarding it as due to toxic and others to mechanical influ- 
ences. In reference to the view advanced that vascular heart disturb- 
ances may exercise an influence on the development of the disease, the 
author reviews the opinions of various writers on the subject and comes 
to the conclusion that in the material offered there is scanty evidence of 
the occurrence of arteriosclerosis as a result of vascular heart troubles 
from trauma, and that the cases cited in support of this origin will not 
bear the test of critical examination. From his own experience he 
describes 108 cases chosen with special reference to the light they might 
throw on this problem. In 169 of these cases, all of whom had long 
suffered from pronounced nervous cardiovascular disturbances, he was 
not able to discover a single instance in which there seemed to be a con- 
nection between the cardiac disturbance and the development of arterio- 
sclerosis. In the remaining 11 cases who before the accident had mani- 
fested signs of beginning arteriosclerosis, the further observation, 
extending over from six to twelve years, revealed no discernible influence 
of the nervous results of the trauma on the arteriosclerosis in the sense 
of an acceleration of its development. [J.] 

Schwartz, L. Dermographism and Vasomotor Disturbances. 
[Deutsche Ztschr. f. Nervenh.. Vol. LX, p. 279.] 

In the search for objective characteristics of psychoneuroses a certain 
significance has always been ascribed to dermographism. The author has 
undertaken a large number of experiments in regard to this phenomena, 
using an improved apparatus and technique. A dull instrument was used 
for producing the dermographia rubra with a pressure of 500 grammes ; 
for the dermographia dolorosa a pointed instrument with a pressure of 
50 grammes. The results showed that the dermographia dolorosa and 
peripherica varies with the age of the individual. There is also a slight 
difference between men and women. It was found that the influence of 
the atmospheric temperature was negligible for the dermographia dolo- 
rosa, but not for the peripherica. and for that reason the latter is of less 
value in making individual experiments than the former. Transitory 
psychic influences on dermographism cannot in all cases be avoided, even 
when the greatest caution is used. The dermographic reaction complexes 
are in general livelier in persons with nervous disease and with nervous 
tendencies than in normal individuals. When cure is effected the suscep- 
tibility vanishes. Some persons with normal nerves react in quite a lively 
manner, hut there is a certain pathological boundary which is not over- 
stepped. Hyperaemic islands are only met with in pronounced psycho- 
neuroses and in organic diseases. There is a very obvious parallelism 



334 CURRENT LITERATURE 

between lively dermographic reactions and certain vasomotor and secre- 
tory disturbances. In neurasthenics the dermographia dolorosa reaction 
is livelier than in hysterics. When repeated examinations of psycho- 
neurotics are made a great variability in results is sometimes manifested. 
In many respects the results of the dermographia dolorosa correspond to 
those of plethysmographic and tonemetric examinations. In regard to 
the cause of the dermographic phenomena the author states that they may 
possibly be due to heightened blood pressure. Weber and Bickel have 
shown that in conditions of mental and physical fatigue and in certain 
nervous diseases, including psychoneuroses, psychasthenic reactions make . 
their appearance when there is pain or mental exertion, expectation or 
sensible stimulation. A cortical paresis of the vasoconstrictors is hereby 
conditioned, and in consequence of the resulting heightened blood pres- 
sure a passive dilatation of the vessels of the skin. In hysteria, where, 
according to Raff, there is no tendency to heightened blood pressure, the 
dermographic phenomena would not be produced, which accorded with 
the results of the author's experiments. [J.] 

Klien, H. Entoptic Perception of the Retinal Pigment Epithe- 
lium in a Case of Migraine. [Zeitschr. f. d. ges. Neurol, u. 
Psychiat., Vol. XXXVI, p. 323.] 

The disturbances of vision and subjective phenomena of light which 
occur in attacks of migraine are of various sorts and have not hitherto 
been explained in an entirely satisfactory manner. There is an inclina- 
tion to refer many of the subjective phenomena, in so far as they are not 
irreconcilable with a central localization, to purely central irritation, or. 
if the disturbances affect only one eye, to an irritation in the optic nerve. 
The author had opportunity to observe a case of migraine in which, 
during the attack, an optical phenomena frequently made its appearance 
which could be explained in no other way than as a process in the eye 
itself. This phenomenon was in the form of a net made up of hexagonal 
meshes covering the entire field of vision; the same appearance may be 
produced experimentally in certain conditions of light or by pressure on 
the bulbus. There is no unanimity of opinion as to its cause, but the 
author interprets it as a perception of the epithelial pigment layer of the 
eye due to unequal stimulation of the elements of this layer. The occur- 
rence of this phenomenon in migraine is explained as the result of varia- 
tions in pressure in the bulbus or of vasomotor disturbances in the retina 
and choroid or as due to the fact that the centrifugal fibers arising in 
the mid-brain and following the path of the optic nerve, which were 
discovered by Ramon y Cajal in birds and by Monakow, Edinger and 
others in man, conduct stimuli which cause movements of plasma and 
chemical processes in the retina. However this may be, the case is of 
neurological interest, proving, as it does, that an optical phenomenon of 
irritation in a case of migraine is caused by peripheral processes in the 
medulla. [J.] 



VISCERAL NEUROLOGY 335 

Latarjet and Thevenot. The Innervation of the Bladder. [Lyon 
Medical, 1919, CXXIII, p. 201.] 

The writers record the results of their experimental study of the 
innervation of the bladder in dogs : all the vesical nerves come from the 
hypogastric ganglion. Some of these reach the ganglion from the 
visceral sympathetic system by the intermediation of the sacral nerve 
and the hypogastric nerves. Others supply to the ganglion filaments 
from the sacral cord by numerous anastomoses between the anterior 
branches of the third and fourth sacral pairs. These anastomoses repre- 
sent in man the erector nerve of Eckhardt, described in the dog. The 
anatomy of the vesical nerves of the dog exactly resembles that of man. 
In the average sized dog the size of the normally distended bladder is 
6 to 7 cm. in height, 4 cm. breadth, and 4 cm. thickness. Twenty days 
after section of the hypogastric nerves at a distance from the ganglion 
(without touching it), the bladder of the animal is small, retracted, and 
free from any trophic lesion or ascending lesion of the urinary tract. 
During life the animal micturates often, in large quantities, and passes 
urine even involuntarily. Slight pressure on the vesical region leads to 
escape of urine by the ureter. After resection of the nervi erigentes 
no urine, or very little, can be passed : then retention becomes complete : 
the bladder distends. In order to prevent complications, the animal was 
sounded twice or thrice daily : at each sounding 200 grammes was drawn 
off. The bladders removed one month after operation are seen to be 
gready distended, their walls greatly thinned, and their capacity more 
than doubled in spite of the daily catheterisms. The effects of resection 
of the hypogastric ganglia resemble those of resection of the nervi 
erigentes, with dysuria going on to complete and progressive retention. 
Unilateral resection gives virtually the same results as bilateral. Thus, 
suppression of the direct action of the spinal cord (section of erigentes. 
removal of hypogastric ganglia) gives paralysis of the urinary reservoir 
and its mechanical distension. The vesical sphincter, then, remains nor- 
mal. But resection of the hypogastric nerves (influence of visceral 
sympathetic) disturbs the sphincter without absolutely abolishing its 
tonicity. [Leonard J. Kidd, London, England.] 

Brouwer, B. A Cerebral Tumor with Bladder Symptoms. [Psychiat. 
en Neurolog. Bladen, 1916, Nos. 5 and 6.] 

A man, 39, had had for eight years precipitate micturition and drib- 
bling, and often incontinence on putting his hands into cold water. He 
had been treated for a chancre by mercurial inunction. For some years 
his wife had noticed sudden attacks of mental "absences": in these he 
could not speak, and his face became fiery red: immediately after them 
he was himself again. Then memory deteriorated, and he could not 
tackle difficult problems. His mental powers declined, and he had head- 
ache : on one occasion rectal incontinence : sexual loss. Examination 



336 CURRENT LITERATURE 

showed choked discs; lively reflexes; a very fine quick tremor in hands 
and legs, worse on voluntary movements, and often increased when stand- 
ing; writing tremulous. Loss of interest in surroundings; mood grave 
and oppressed. Orientation good in all respects; but he cannot fix his 
attention. Memory bad for old and also recent events. Slight catalepsy. 
Occasionally is anxious, without knowing why. There was absence of 
sensory changes, of pyramidal involvement, of nystagmus, of frontal 
ataxy, of gait-difficulty, of power of reading, speech affection, of apraxia, 
of signs of Basedow's disease, and of morid (witzelsucht). Often he 
would jump out of bed at night for no obvious reason. Lumbar puncture 
showed increased pressure of spinal fluid. It did no good; but his head- 
ache became worse, temperature rose, and he died on the third day after 
the puncture. There had been a normal Wassermann in blood and in 
spinal fluid, and the bladder symptoms persisted up to his death. 
Necropsy showed a tumor which included both frontal lobes, but left the 
cerebral cortex free; it invaded the corpus callosum, and contained large 
softened spaces in its interior, into which hemorrhage had occurred. It 
had destroyed the anterior part of the callosum, and the septum lucidum, 
and on both sides reached the pole of the frontal lobes, and invaded the 
ventricles, which showed hemorrhages. In the striatum the head of 
the left caudate nucleus was destroyed, and part of the right caudate; 
and there was a small gliomatous focus in the lenticular nucleus which 
was otherwise free. Slight involvement of right internal capsule. The 
callosum shows a small focus. Brouwer says that death was not due to 
the lumbar puncture, but to the acute alteration of pressure relations 
caused by the intra-ventricular bleeding due to the relief of pressure on 
the f ronto-callosal tumor by the puncture : frontal tumors often cause 
sudden death per se. The tremor in the limbs resembled that described 
by Grainger Stewart in the homolateral limbs in cases of unilateral frontal 
tumors. Brouwer discusses the question of cerebral vesical centers 
(cortex, striatum, thalamus), and concludes that frontal tumors do not 
give important vesical symptoms unless they involve the striatum: the 
same is true of callosal tumors. From his case and from a survey of the 
literature he suggests that there must be a functional localization in the 
striatum, viz., (1) in its lateral parts — the lenticular nucleus — an influence 
must be exercised on the tonus and the regular discharge of reflex move- 
ments by the striated muscles, and (2) in its medial part — the caudate 
nucleus — one on the tonus and reflex movements by the unstriped muscles, 
including probably the rectum as well as the bladder. (In the discussion 
on this paper, Muskens said that in one case of operative callosal punc- 
ture — destruction of brain-stem by a large tumor of the pontile angle — 
there was for a week urinary incontinence and a severe homolateral 
gluteal bedsore.) [Leonard J. Kidd, London, England.] 



VISCERAL NEUROLOGY 337 

Abelous, J. E., and Soula, L. C. The Cholesterinogenic Function of 
the Spleen. [C. R. de 1'Acad. des Sciences, 1920, CLXX, p. 619.] 
In the course of a research on the action of secretion the writers 
found that injection of dilute hydrochloric acid into the duodenum leads 
to an increase of the amount of cholesterin in the arterial blood. This 
hypercholesterinaemia is not produced in splenectomized dogs or rabbits, 
nor after previous ligature of the splenic hilum. Indeed, there is often 
a hypocholesterinaemia. But the blood of the splenic vein contains more 
cholesterin than the arterial blood. Further, there is always more 
cholesterin in the blood of the splenic vein than in that of the sub-hepatic 
veins. In all their experiments the writers used Grigaut's method of 
extraction of cholesterin. They record some experiments in vitro in 
demonstration of their conclusion that cholesterin is formed in the spleen. 
The spleen has a much greater cholesterinogenic function than the liver 
and the adrenals. [Leonard J. Kidd, London, England.] 

2. ENDOCRINOLOGY. 

Kretschmer, Ernst. Familial Endocrinopathies. [Zeitschr. f. d. 

ges. Neurol, u. Psychiat.. Vol. XLVI, p. 79.] 

In a family that fell under the author's observation he discovered a 
cangCBital condition of somatic and psychic degeneration which affected 
principally the male members and seemed to be directly inherited from 
father to son. The manifestations were as follows: eunuchoidism (small 
testicles, long limbs, imperfect junction of epiphysis, small skull, flat 
occiput), acromegalic development of nose, hands and feet, changes in 
the sella turcica (perceptible without Roentgen picture), disturbances of 
the heart vessels (variability of the pulse frequency, arteriosclerosis), 
dermographia, venous spasms, lymphocytosis, psychic inferiority, 
arthropathies with selective affection of the vertebral column and knee 
joints. There was also a peculiar disease of the muscles which in the 
loin musculature could be regarded as pseudohypertrophy with fatty 
formations, and in the rest of the body, especially in the shoulder region, 
as muscular hypertrophy without increase of function. This condition, 
in the center of which stands the testicle hypophysis complex, is probably 
to be interpreted as a polyglandular syndrome, because it can be directly 
referred in part to known endocrine disturbances and. for the rest, can 
be understood as due to such disturbances. [J.] 

Gutman, J. The Ductless Glands and Constitutional Diagnosis. 
[Med. Rec, April 3, 1920.] 

In this presentation the author calls attention to the necessity of 
studying the individual from the constitutional standpoint and not merely 
from the morphological one. He refers to the dependency of pathologic 
syndromes upon the constitutional habitus of the individual affected, and 



338 CURRENT LITERATURE 

points to the close relationship existing between constitutions and the 
endocrine glands. He calls attention to several fundamental facts which 
influence the nature of human constitutions: 

(1) The effects of the inherited powers of the endocrines upon 
development ; 

(2) Their control of the vital metabolic processes; 

(3) Their domination of the important functions occurring during 
the three cycles of life; 

(4) Their intimate relationship and cooperative method of function- 
ing; and 

(5) The consequences following their disturbances, physiologic or 
pathologic. 

The author further proceeds to elucidate the principles mentioned. 
In regard to the first, he claims that every particle of protoplasm, every 
granule of the impregnated ovum, carries within it the essence of the 
parental ductless glands and, hence, all those elements which transmit to 
the offspring the racial, national and familial characteristics of its pro- 
genitors. These endow the child with the phenomena which we com- 
monly consider inherited. They determine the features which identify 
the offspring as Caucasian or. Mongolian, Scandinavian or Italian, Gentile 
or Jew. They determine the unique expression, character, habits, traits, 
ambitions, talents, longevity and idiosyncrasies peculiar to its race and 
family. The writer classifies human beings into four types: the thy- 
rotrop, adrenotrop and pituitotrop, which are understood to be pure 
types, and a fourth class the mixed type, including individuals with 
features characteristic of two or more pure types. These types, tropisms 
or constitutions are defined not only by characteristic external features, 
but also by the mental and psychic phenomena of the individual. The 
pathological disturbances also follow closely the constitutional habitus of 
an individual. The morbid phenomena which we were taught to look 
upon as hereditary are so only because they affect people of similar 
glandular tropism. It is a commonly known fact that apoplexy, diabetes, 
arterio-sclerosis, interstitial nephritis, affect individuals of a certain type, 
known as status apoplecticus, and practically never occur in another type 
of subjects, the thymico-lymphatic. On the other hand, chlorosis, tuber- 
culosis, hemophilia, lymphadenoma, are known to affect thymico-lymphatic 
individuals and seldom the first mentioned type. This is due to the fact 
that these two types are made of two very dissimilar fabrics, are of dif- 
ferent constitutions originating from two different endocrine sources, 
the adrenals on the one hand, the thymus on the other. Two beings of 
the same species Homo, but of different breeds, of unlike physical and 
mental capacity. This fact is of great practical value in diagnosis, 
because the relationship of morbid phenomena, functional and morpho- 
logic, is definite and characteristic of each type or tropism. It is also of 



VISCERAL NEUROLOGY 339 

help in therapy because it enables the substitution of polypharmacy, 
empiricism and theurapeutic nihilism by individualistic and accurate 
opotherapy. 

In reference to the endocrine control of metabolism, the author states 
that the growth and form of our organs depend upon the influences of the 
glands of internal secretion which they exercise through metabolic con- 
trol. Whether an individual is to be tall or short, lean or corpulent, 
graceful or awkward, is all dependent upon the peculiar reactions of the 
different endocrine glands, individually and collectively ; it depends upon 
whether they functionate harmoniously or discordantly; upon the possi- 
bility of overworking one gland and relaxing another. He further cites 
examples of the remarkable changes occurring when a gland for some 
reason or another undergoes hypertrophy or atrophy in individuals dur- 
ing the period of their development ; the astonishing changes in growth, 
mentality and sexuality of those affected by an overgrowth of the anterior 
pituitary with the result of acromegaly; the marked changes in the 
metabolic rate, sugar tolerance, oxygen consumption and urea formation 
in those affected with thyroidal disease; the unusual features of the 
eunuchoid type which even the layman quickly recognizes and thinks 
peculiar. This is because normally each and every endocrine is endowed 
with a definite function, within definite limits and with a prescribed rate 
of metabolic exchange determined by the physiologic activity of the 
organs under its control ; under abnormal conditions, the metabolic rate 
is altered, some functions are augmented, others are increased, and a 
metabolic imbalance thus occurs. 

The third principle upon which constitutions are built and in which 
the domination of the vital functions by the endocrines is shown is illus- 
trated by the example of a cat suddenly confronted by a dog. The sight 
of the enemy brings to the cat's consciousness a vivid picture of danger. 
The mechanism of defense and offense are brought into play when these 
two are brought together by chance. The biologic mechanism whereby 
consciousness dictates an order requiring execution is directed to the 
adrenals, where the activating hormones which convert the static into 
kinetic energy are stored in sufficient quantities to meet all emergencies 
and activities in the life of the animal. Vasomotor energy is known to 
be concentrated to a greater extent in the adrenals than elsewhere. By 
various efferent paths orders are issued to check immediately all imma- 
terial activities in organs not called for in the defense or flight of the 
animal. Thus, gastric digestion, intestinal absorption, sexual activity and 
similar functions are ceased, while oxygen, glycogen and other material 
necessary for the most strenuous function of the defensive organs is 
mobilized through the agency of the vascular and nervous systems to the 
muscles, nerves, brain, etc. Thus, the cat's brain is cleared for full 
action, the mind is freed from all immaterial thought, the sight is sharp- 



340 CURRENT LITERATURE 

ened, the hearing made most acute, the cardio-respiratory apparatus pre- 
pared for forceful action, the muscular system is loaded with kinetic force 
and prepared to spend it all in the struggle for dear life of its owner. 
All this is accomplished primarily through the endocrine system and 
secondarily through the vegetative nervous system under the control of 
the former. 

The author next discusses the relationship of the endocrines to each 
other, calling attention to the predominance of certain of the glands in 
certain individuals and the control of the cycles of life in all individuals 
by others. At certain definite periods of life certain glands play a lead- 
ing role in the development and physiological interpretations of the 
organism. All others, however, at all times cooperate harmoniously with 
the leader. Such united action is necessary to keep the individual in 
perfect balance and to serve his economy best. The leading gland deter- 
mines the architecture and creates an individual of its own type; the 
others assist in this work. Under normal circumstances harmony pre- 
vails at all times. If, however, the leading gland or any other of its 
associates, because of special stress, suffers exhaustion and becomes 
unable to respond further to its task, the remaining glands hasten to its 
rescue and to assume its responsibilities. Such cooperation preserves a 
normal balance. They cause a hyper or hypofunction of the organs 
under their own control to substitute the deficiencies of the organs 
controlled by the exhausted gland. 

In discussing the fifth basic principle of endocrine constitutionalism 
the author shows the effects of deficient glandular inheritance and states 
that individuals born with defective glands show most decided morpho- 
logic and functional distortions. In those, on the other hand, in whom 
the glands become defective in later life, the symptoms presenting them- 
selves depend entirely upon the extent and nature of involvement. Glands 
need not be incapacitated in all their valencies; they may fail in a few 
of their multiple functions and remain active in all others. Some glands 
will withstand the strains of life and functionate a lifetime, while others 
may fall by the wayside. Such incidents as infections, school life, 
puberty, courtship, marriage and childbirth may be the rock upon which 
the constitution of an individual endowed with poor quality endocrines 
may founder. 

In conclusion, the author brings proof to sustain his argument that 
it is absolutely essential in the making of an honest and scientific diag- 
nosis to dispense with the idea, that when a condition is labeled with a 
pathological name everything possible has been accomplished in the study 
of the case. No diagnosis is complete unless the case lias also been 
studied from the endocrinologic viewpoint, for it helps one to decipher 
the whys and wherefores of the case and offers a more precise and more 
satisfactory explanation of encountered conditions not otherwise explain- 
able. It enables one to individualize in diagnosis and to apply therapy 
which is suited to the case and is rational. [Author's abstract.] 



VISCERAL NEUROLOGY 341 

Sterling, W. " Degeneratio Genito-sclerodermica " as Pluriglandu- 
lar Insufficiency. [Deutsche Ztschr. f. Nervenh.. Vol. LXI, 
p. 192.] 

The author proposes a paradigm for a separate dyscndocrine symptom 
group and describes three cases as examples. They are cases of young 
women who were previously healthy and whose menstruation periods sud- 
denly ceased. Simultaneously with the cessation of menstruation, which, 
the author states, may set in without any discoverable cause, or after a 
psychic shock or an infectious disease, a symptom complex develops 
resembling the so-called late eunuchoidism combined with cachexia, 
emaciation, inanition and, frequently, diarrhea. The expression of the 
face changes perceptibly and becomes aged, in marked contrast to the 
expression in ordinary eunuchoidism, where the expression of youth, even 
in aged persons, is a characteristic symptom. Parallel with these phe- 
nomena the cutaneous symptoms set in, at first being localized and super- 
ficial, but later becoming general, involving not only the entire surface 
of the body, but, in some instances, extending to the deep-lying parts and 
even to the bones. Reviewing the voluminous literature on gynecology, 
sclerodermy, neurology and inner secretions, the author was able to find 
isolated cases which could be grouped with this disease picture. He 
describes 25 combinations of scleroderma with inner secretory diseases, 
stating that these concurrences seem to be more than coincidences. It 
has been shown that scleroderma is connected with a hypertony of the 
sympathetic system. The inner secretory glands are also dependent on 
the regulatory and nutritive influences of this system. If any one of the 
inner secretory glands fails to functionate the hormone balance may be 
restored by a hyper functionating of another gland. The sympathetic 
system may be affected by the disharmony so that equilibrium is not 
restored, and when the compensatory activity fails the symptoms of pluri- 
glandular insufficiency make their appearance, one form of which con- 
stitutes the disease picture described by the author to which he has given 
the name M degeneratio genito-sclerodermica." [J.] 

Frazier, C. H. Choice of Method in Operations on the Pituitary 
Body. [Surgery, Gynecol., and Obstetrics, XXIX, July. p. 9 (12 
Figs.).] 

The methods of surgical approach to the pituitary body have In time 
and experience been narrowed down to two : the submucous septal < endo- 
nasal ) and Frazier's fronto-orbital (cranial) operation, recently modified 
by him. By the endonasal method the possibility of meningitis has to be 
reckoned with, for even in healthy subjects the sphenoidal sinuses may 
contain contaminating organisms. In the fronto-orbital operation 
approach to the sella may be made without invading a contaminating 
field, provided we avoid the frontal sinus. The endonasal method gives 
a cramped field of operation, and depends on artificial light. When, as 



342 CURRENT LITERATURE 

often happens, there is extra-sellar extension of the disease, the fronto- 
orbital gives a much better view of the field of operation. In the man- 
agement of cysts, which occur in about 10 per cent of cases of pituitary- 
adenomata, the fronto-orbital method has this great advantage, that it 
enables the operator to expose the cyst by the direct supra-sellar approach 
and then to remove a portion of the wall in order to prevent filling up of 
the cyst which occurs when mere puncture is used. Another restriction 
to the endonasal method is in the case of the undeveloped sinuses in 
children. Ultimately the choice of operation will depend on the end — 
results of operation. But Frazier believes the fronto-orbital method — 
which he describes once more — will be found to have a wider field of 
application than the endonasal. He seems to have overcome the cosmetic 
objection to the mid-forehead incision of his operation by means of 
closure of the wound by epidermal suture. [Leonard J. Kidd. London, 
England.] 

Sajous, Chas. Fluctuations of Thyrosuprarenal Activity in Gen- 
eral Disease. [New York Medical Journal, February 14, 1920.] 

In the course of his paper the author reviews several features of 
endocrinology which bear directly upon nervous and mental diseases. 
Recalling that in 1903 he had pointed out that the secretion of the 
adrenals contributed to the blood the previously unknown constituent of 
the hemoglobin molecule which enabled it to become converted into 
oxyhemoglobin, he refers to the physiological studies of Menten and Crile 
as confirming this view. The author had also traced the oxidizing sub- 
stance thus formed by the adrenal secretion in the lungs, and which he 
terms " adrenoxidase," in all tissues including the entire nervous system, 
the axis cylinder acting as centrifugal channel (as it does for tetanotoxin, 
for example) for this oxidizing agent. The presence of adrenalin in the 
axis cylinder of nerves had been confirmed by Lichwitz and, in so far as 
sympathetic nerves were concerned, by Macallum. Tashiro had recently 
confirmed, moreover, the author's older contention that nerve fibers and 
the ganglia particularly were the seat of as active metabolism as any tissue 
in the body. Sajous also recalls that his view that strychnin produced 
its effects by exciting the adrenals — a fact which accounts for its vigorous 
action on the nervous system, through the increased adrenoxidase — had 
recently been confirmed by Stewart and Rogoff. He then shows that 
many obscure disorders, the senile " pneumonia " which carries off most 
aged subjects, for instance, are the result of adrenal failure, wax injec- 
tion of their adrenal vascular network showing plainly when compared 
with similarly treated adrenals, that the vascular supply of the adrenals 
steadily declines as age advances. 

The author attaches considerable importance to the thyroid gland in 
various nervous disorders, and illustrates his contention by the prominence 
of such disorders in Graves's disease, long considered, in fact, as a 



VISCERAL NEUROLOGY 343 

neurosis by many leading clinicians. In this and other disorders he 
regards hyperthyroidism as a result of excessive defensive activity, his 
view that the thyroid hormone is a component of the systemic antitoxins 
or alexins having been repeatedly confirmed in Europe. Under the 
influence of a focal infection, dental, tonsillar, intestinal, etc., the thyroid 
may thus, in the course of a defensive reaction, break down not only the 
systemic fats, but also the phosphorized fats constituting the myelin of 
nerves, and thus provoke lesions therein. He explains in this manner 
the beneficial effects obtained by Berkley, Follis and others from partial 
thyroidectomy many years ago in appropriate cases of dementia precox, 
and those reported by Byron Holmes, obtained by flushing the cecum and 
colon through an appendicostomy opening, to overcome intestinal stasis. 
The author also cites a case of his own due to cecal stasis, selected owing 
to its severity, and identified as a case of dementia precox by several 
prominent psychiatrists. In this patient, aged \A l / 2 years, a cecotomy 
permitting daily flushing was performed, and a diet rich in fats and 
lecithin orally, brought about recovery, now of" nine months' standing, 
with total disappearance of periodical paroxysms requiring the strait- 
jacket, the patient having gained 47 pounds in weight the first five 
months following the operation. [Author's abstract.] 

Weill, E., and Dufourt, A. Virilism in a Girl of Fourteen Years. 
[Lyon Medical, p. 620.] 

The author reported to the Medical Society of the Lyons Hospital 
a case of virilism in a girl aged 14. She was normal till she was 10. 
Then her skin became rapidly covered with hair : within a few months 
she had a thick beard and moustache, but the hair of her head fell out 
considerably. She was in general of masculine type: breasts absent; 
male voice, thorax, and pelvis ; her muscular power was great. No 
menses have appeared. Her psychical state tends to neurasthenia. The 
clitoris and labia majora are enormously hypertrophied. but the vaginal 
and urethral orifices are normal and normally situated. Her thyroid is 
rather large, without myxedema or exophthalmic goiter. There is slight 
achondroplasia of her limbs. No adiposity. No signs of pituitary 
involvement; sella normal by radiography. Cerebrospinal fluid normal. 
There are no detectable signs of the presence of any adrenal tumor. As 
a rule, these cases of virilism in the female coexist with ovarian aplasia 
and tumor of the adrenal cortex. [Leonard J. Kidd.] 

Curschmann, Hans. Epilepsy and Tetany. [Deutsche Ztschr. f. 

Nervenh.. Vol. LXI, p. 1.] 

The author opposes the view of Bolten that in the majority of cases 
epilepsy and tetany are not due to a common pathological cause, but to 
the coincidence of parathyroid tetany and cerebral epilepsy. Bolten 
claims that a true pathogenic connection could only be certainly proved 



344 CURRENT LITERATURE 

where a goiter had been removed. Here the destruction of the para- 
thyroid function would produce tetany; if the thyroid and parathyroid 
functions were both destroyed the result would be epilepsy and tetany, but 
if these functions were only congenitally reduced the result would be 
epilepsy; epilepsy and tetany where there was congenital absence of the 
thyroid and parathyroid could not be distinguished, however, from 
numerous other cases where there was only coincidence of the two 
diseases. According to the author, the occurrence of epilepsy and tetany 
as result of hypothyroidism can be clearly distinguished from attacks of 
other etiology by the accompanying myxedematous phenomena, as well 
as by the facts that both forms of convulsions occur simultaneously and 
decrease simultaneously, and that both are influenced by the administration 
of calcium. Additional proof of the close relationship of these two 
phenomena is that after the appearance of the purely epileptic attacks 
the stigmata of tetany (the hyper-irritability of Chvostek, Erb and Trous- 
seau) are simultaneously intensified. From experiments with calcium 
it has been ascertained that the irritability of the brain is influenced by 
the absence of the parathyroid functions — wholly independently of the 
thyroid itself. The epithelial cellules by means of a hormone influence 
the calcium metabolism in the central nervous system, the absence of the 
function results in a poverty of calcium in the entire central nervous 
system inclusive of the brain. It has further been proved in animals 
deprived of the parathyroids that when calcium is administered or with- 
held the effect on the brain resembles very closely the effect of calcium 
on the peripheral nerves. It is therefore a poverty of calcium in the 
cortex cerebri, due to parathyroid insufficiency (without any necessary 
concurrent disturbance of the thyroid), which leads to pure parathyroid 
eclampsia or epilepsy, and which may also produce the tetany poison. 
From the author's experience there is not rarely a " late spasmophile " 
epilepsy in which after a period, sometimes of short duration, true 
epileptic attacks seem to grow out of the spasmophile diathesis with its 
eclampsic convulsions — a further proof of the parathyroid origin of 
epilepsy. The author cites a case in illustration of his views. Further, 
he discusses the role of the thyroid gland as a temperature regulating 
organ, quoting Bolten and others, who state that in animals deprived of 
the thyroid convulsions can be produced by raising the temperature. He 
has observed the same phenomenon where there was insufficiency 
exclusively of the parathyroids. [J.] 

Roeder, C. A. Toxic Goiter and Influenza. [Surg., Gyn., Obstet- 
rics, April, 1920, p. 357.] 

Our knowledge of the pathology and symptomatology of goiter and its 
internal secretions has greatly increased in the past few years owing to 
the work of Plummer, McCarty. Wilson and Kendall of Rochester. The 
previously indefinite confusing terms, such as struma, strumous thyroiditis, 
thyroiditis, etc.. have been replaced by more definite terminology, such as 



VISCERAL NEUROLOGY 345 

hyperthyroidism (exophthalmic goiter), which is always accompanied by 
columnar epithelium lining the acini, and degenerating adenomata, con- 
sisting of masses of thyroid tissue surrounded by connective tissue, which 
so interferes with a normal blood supply and resorption that a toxin is 
given off. attacking primarily the cardio-vascular system. These two 
types represent the toxic goiters. The other type added was the colloid, 
so that now we speak of non-malignant goiters as (1) exophthalmic, 
(2) adenomatous and (3) colloid. 

The etiology of all types is still the same mystery, and various author- 
ities have thought that emotions, injuries, exhaustion, infections, etc., 
were factors of importance, but no definite link could be established satis- 
factory to medical men in general. Of late the infection theory seemed 
more acceptable. Of the many complications following epidemic influ- 
enza. Roeder (Surg., Gyn., Obst., April, 1920) reports eight marked cases 
of toxic goiter (3 degenerating adenomata and 5 exophthalmic) coming 
on immediately after the attack of influenza. Only a few weeks at the 
most elapsed between the infection and the onset of toxic symptoms 
which definitely established the etiology. These cases gave a history of 
no symptoms previous to the attack of influenza, although several of the 
toxic adenomatous cases had noticed a small goiter for some time previ- 
ously but of practically negative significance. An operation was required 
and resulted successfully in all cases. [Author's abstract.] 

Zondek, H. The Mvxoedemheart and Its Treatment. [Munch. Med. 
Woch.. 1918, No. 43, pp. 1180-1182; 1919, No. 25, pp. 681-683.] 

Not all dilatations of the heart are due to a valvular defect or to the 
usual forms of heart muscle diseases. Through a number of striking 
examples the author shows that an insufficiency of the thyroid gland 
often leads to an expansion of the auricles and chambers of heart, 
which sometimes attain an enormous extent. This fact is accompanied 
with a marked relaxation of the pulse, which then only counts 60-50 pulsa- 
tions. The action of the heart shows, when brought under the Roentgen 
glass, not only a distinct relaxion, but also a great superficiality and 
mertion. This quite corresponds to the dull and sluggish impression of 
the patient. Another particular feature of the myxoedemheart is the 
Elektrokardiogramm. The auricle elevations as well as the subsequent 
oscillation are absent. The absence of the former can also be proved 
by the curvings of the venous pulse. The subjective complaints of the 
patient are generally connected with the original disease. They con- 
tinually suffer from chilly feelings and pasty swelling of the face and 
limbs, they lose their hair, the skin becomes unnaturally dry and the 
hands assume the appearance of paws, etc. As far as the heart is 
concerned, the patient must often complain of shortness of breath and 
flappings of the heart, and a slight cyanosis is also no seldom symptom 
of this disease. Not only the objective condition of the heart, but also 



346 CURRENT LITERATURE 

the subjective complaints of the patient will be cured with success 
through thyreoidin, which must be taken in the form of powders, daily 
three times, during a space of eight weeks, and then, with interrup- 
tions of three weeks, at least six or eight months. The dilatations of the 
heart disappear. It is not unusual that the transversal diameter of the 
heart diminishes and becomes 6-7 cm. smaller. The action of the heart 
becomes more animated. The action of the pulse increases, and gradually 
the failing notches of the elektrokardiogram reappear. When these have 
attained their usual height, then the patient may cease taking the thy- 
reoidin powders. We also undoubtedly find abortive forms of myxoedem 
with transformations of the heart, such as we have just described. In 
such cases it is always very important to bear in mind the possibility of 
a thyreogene genesis, for the digitalis therapy proves quite useless here. 
[Author's abstract.] 



II. SENSORI-MOTOR NEUROLOGY. 
1. PERIPHERAL NERVES: RADICULAR SYNDROMES. 

Kronthal, Paul. Biology and Functions of Nerve Cells. [Neurol. 
Centralbl., 1919, May 16, Vol. XXXVIII, No. 10, p. 321.] 
The author asserts that the idea of the nerve cell as an organism is 
without scientific foundation and that the concept of its function as 
giving rise to stimuli is at variance with experience. The facts really 
known concerning the nerve cell may be summed tip as follows: fibrils 
are very fine threads and white blood cells flow about them; the gray 
substance is extraordinarily rich in fibrils and it is also surrounded by 
numerous spaces containing white blood cells which migrate into the 
tissue. It would therefore be expected that in the gray substance white 
blood cells would be found surrounding the fibrils. The result would be 
;t formation answering the description of the nerve cell, and we have 
inferred the very process by which, in the embryo, the nerve cell is 
formed. In the embryo, as later, the migrating cell is arrested by an 
element foreign to it, i.e., the fibril which holds it fast and penetrates its 
body. This explanation, according to the author, accounts fully for the 
various forms of nerve cells and also for the otherwise wholly inexplicable 
presence of nuclear substance in them. When a sensory apparatus is 
stimulated, not one, but a large number of muscle cells contract. This 
would only be possible if the insulation of the motor path to a single 
muscle were removed, and the function of the nerve cell in conjunction 
with the fibers which traverse it is to remove this insulation. The 
motions which follow from stimulation of the brain cortex are simply 
results of the irritation of the fibers. All motions from the simplest to 
the most complex Can be explained in this way, leaving no room for 
metaphysical interpretation, in the sense of a soul situated in the brain. 
The only function of the nervous system is to conduct stimuli, and for 



SH.XSORI-MOTOR NEUROLOGY 347 

this performance the nerve fiber is of more importance than the nerve 
cell, and it is therefore found in the lower forms of animal life and in 
the embryo before the cell is developed. The nerve cell is the point 
where the stimuli pass to various different fibrils and it neither gives 
rise to stimulus nor is it a nutritional center for the fiber. [J.] , 

Spielmeyer, W. Regeneration of Peripheral Nerves. [Zeitschr. f. 

d. ges. Neurol, u. Psychiat.. Vol. XXXVI, p. 421.] 

The author, presenting the essential points concerning the regenera- 
tion of nerves from his observations in the war, sums up the anatomical 
processes for central as well as peripheral nerves that have been divided 
as follows : The newly formed nerve fibers are of polyneuclear origin, 
and it is from Schwann's cells that the new nerve fibers take their 
origin ; the Cells of Schwann as an ectoderm formation do not merely 
constitute an " adequate medium " for the growth of the nerve fibers 
proceeding from the central end; the nerve fibers, as such, do not 
"' sprout " and the ganglion cells do not thrust their neurites forward. 
What takes place is that in the Schwann's element projecting from the 
central end, as well as in the ligament fibers of the peripheral section, 
the new fibers originate, and in the chain of Schwann's cells the " neuro- 
fibrillary differentiations" (Borst) takes place. In the adult organism 
the complete construction of real nerve fibers, however, only occurs with 
the cooperation of ''central stimuli " (Bethe). It is the processes in the 
peripheral part of the nerve cut off from the center which prove the 
neuroblastic properties of the Schwann's cells. The transformation of 
the undifferentiated ligament fibers into nerve-like threads can be inter- 
preted in no other manner and furnishes conclusive demonstration of the 
fact that the chains of cells in the central section are not simply conduc- 
tion paths for the outgrowing new nerve fibers, but that the Schwann's 
cells produce the nerves themselves under the influence of central stimu- 
lation. It is seen that the establishment of this fact is a confirmation of 
the much discussed theory of Berthe. The author recognizes the diffi- 
culty of reconciling his histological view with that which regards these 
elements as genetically and histologically nothing more than " peripheral 
glia cells." Diirck has also abandoned the view that the function of 
these cells is to " carry the phagocytes," and though formerly the author 
was an adherent of the theory that Schwann's cells functionate as a 
peripheral glia element, he is at the present time not in a position to a 
decisive attitude toward this question. He can only reaffirm that he 
considers the neuroblastic properties of the Schwann cells to be definitely 
established by his findings. A not unimportant confirmation of this 
view is an experience from general pathology, namely, that there are 
neoplasms, true neuronomas or neuronomas without ganglion cells where 
proliferating Schwann's cells have become tumors with fully developed 
medullary fibers. Borst has described an example of this sort. It is 
impossible to assume for these neoplasms that the elements from which 



348 CURRENT LITERATURE 

they originate are ganglion cells in the spinal cord, and there is no other 
view possible than to regard the Schwann elements as the real source 
from which the neoplasm containing medullary fibers is formed. [J.] 

Pallasse and Delorme. Cervical Zoxa with a Generalized Eruption. 

[Lyon Medical, August, 1919.] 

The author reported to the Lyons Society of Medical Sciences on 
June 25, 1919, a case of zona of the whole cutaneous area supplied by 
the left superficial cervical plexus, accompanied by an intense generalized 
polymorphous vesicular eruption resembling varicella. The patient, a 
man, aged 65, was slightly alcoholic: physical examination showed merely 
a little emphysema. The herpetic eruption appeared first as an erythema, 
with heat, local hyperaesthesia, and intense general symptoms; Vesicks 
appeared on the next day. There were numerous Vesicks disseminated 
over the face, trunk, and limbs, without any definite localization on the 
course of any nerves. There were no meningeal symptoms, yet lumbar 
puncture on the sixth day showed the presence of a pure lymphocytosis 
with a hyperleucocytosis of Nageotte's cells (40 elements to the cubic 
millimeter). The case is held to support Landouzy's theory of the 
specific infectious nature of zona. [Leonard J. Kidd.] 

Dollken. Heterovaccine and Nerve Paralysis. [Neurol. Centralbl., 

1919, June 1, Vol. XXXVIII, No. 11, p. 354.] 

The strong neurotropic effects of various bacteria and bacterial 
preparations in corpore and in vitro is well known, as, for instance, the 
virus of tuberculosis or hydrophobia. The author describes the reactions 
of nerve lesions after injection into the body of heterovaccine and 
albumin cleavage products which, he states, have never up to the present 
time been described. He observed the effects on the peripheral nerves of 
injections of prodigiosus-staphylococcus vaccine (vaccineurin) in more 
than 150 cases of neuritis. If 1/200 ccm. of the vaccine is injected into 
the circulation three distinct phases of reaction are discernible. There 
is first a latent period of from 30 to 40 minutes and then the general 
symptoms and those due to the effect on the lesion set in. About one 
and one-half hours afterward the effect on the lesion becomes distinctly 
manifest. If the reaction is positive there is increased pain in the dis- 
eased sensory nerves and phenomena of irritation. In a paralyzed facial 
nerve there is often irregular twitching; if the peroneus is affected, 
irregular movements of the toes ; in disturbances of the sciatic, spreading 
of the toes; of the acoustic nerve, subjective noises. If the reaction of 
the lesion is negative there is cessation of pain, a slight feeling of numb- 
ness, lessened sensibility of the nerve stem. This latter reaction occurs 
ii from 15 per cent to 20 per cent of the cases. It has been conclusively 
ptoved that the negative reaction is really one of the lesion which depends 
on a simulation of the nerve ending, and that the process is not merely 



SEXSORI-MOTOR XEUROLOGY 349 

i neutralization. If the first intravenous injection produces positive reac- 
tion of the lesion, another injection after an interval of 36 hours will 
usually produce a second one of the same sort, but a second injection in 
a shorter time is without effect, as there seems to be a sort of saturation 
of the nerve. In three cases the author saw both positive and negative 
reactions as result of the same injection. The phase of maximum effect 
sets in six hours after the injection and is characterized by a return of 
function of the diseased nerve. If the toxicity of the bacillus prodigiosus 
is decreased the lesion reaction is reduced and the maximal effect is not 
attained. Parallel experiments with pseudodiphtheritic vaccine rich in 
albumen and with deuteroalbumose produced the same lessened reaction 
as the weakened vaccineurin. The effect of these latter substances is 
due to the protein action, and the author sees in the results proof that 
the bacterial albumin and its decomposition products are not the active 
principle of the vaccineurin. The decomposition product of the vacci- 
neurin (toxin), like that of the protein, has an activating effect on the 
protoplasm in the sense of Weichardt, but these effects are selective and 
the organotropic tendencies of the two substances are very different; 
the vaccineurin is pronouncedly neurotropic, while milk develops the 
strongest effect on the liver and joints. To produce progressive and 
permanent therapeutic effects the injections must be repeated at intervals. 
The author describes in detail 16 cases treated by him. [J.] 



Bruijning, F. 0. Herpes Zoster and Varicella. [Nederl. Tijdschr. 
v. Geneeskunde, 1919, Sept. 20, p. 826.] 

The writer records a case of herpes and varicella occurring in the 
same patient. A man was admitted as a case of facial erysipelas. He 
had felt heavy and two days previously his face became painful; he 
vomited, was shivery, but had no headache; he had been feverish. He 
had never had erysipelas, and there was no wound; last year he had an 
apoplexy. He shows redness and swelling of the left face, bounded by 
the middle line; he has superficial gangrenous spots and vesicles above 
the region of the left V 2 nerve; left corneal reflex slightly diminished. 
No other signs. Temperature 39.1°. Four days later the temperature 
began to decline, but the same afternoon Bruijning was called to see the 
patient, who now showed abundance of varicella vesicles, quite typical. 
Rapid recovery from the varicella. Bruijning notes that, in contrast 
with Bokay's cases, his own case showed a declining temperature at the 
onset of the varicella. Further, the vesicles did not specially occur in 
places pressed on by the clothing, nor were they localized in any- 
particular nerve area. [Leonard J. Kidd, London, England.] 



350 CURRENT LITERATURE 

Ouillain and Barre, J. A Fatal Case of Landry's Ascending Paraly- 
sis Following Rapidly on Anti-typhoid Inoculation. [Presse 
Medicale, 1919, XXVII, July 24, p. 410.] 
• The writers reported to the Paris Neurological Society on July 3, 
1919, a typical case of acute Landry's paralysis beginning in the lower 
limbs and passing up the trunk and upper limbs to the face; death by 
bulbar symptoms. The patient was a man in perfect health when he was 
inoculated with 1 c.m.c.5 of the " T. A. B." vaccine. On the same even- 
ing the Landry's symptoms set in. The spinal fluid showed only slight 
lymphocytosis. The connection between the inoculation and the paralysis 
seems to have been clear. ( Several cases of corneal herpes have occurred 
very soon after inoculation by this " T. A. B." vaccine, but not always 
after the first one.) [Leonard J. Kidd.] 



Grube, K. Blood Sugar in Cases of Diabetic Neuritis and Neu- 
ralgia. [Deutsche Ztschr. f. Nervenh., Vol. LX, p. 302.] 

The author describes seven cases of diabetic neuritis in which there 
was moderate glycosuria which could be. influenced by the diet. The 
neuritic phenomena, however, notwithstanding the light form of glyco- 
suria, were serious and prolonged, and in some respects did not recede at 
all. After a time it became apparent that in contrast with the reduction 
of the sugar content in the urine the abnormal blood sugar content for 
a considerable period showed no diminution and could only be influenced 
very slowly. The author assumes that the neuritic phenomena were 
caused by this excessive amount of sugar in the blood, the sugar itself 
or some by-product of it acting as an irritant on the nerve tissue. 
Under these circumstances the diabetic neuritis would have an origin 
analogous to that of alcoholic neuritis. Blood sugar seems frequently to 
produce impotence, and this result may be brought about in the same way 
as the neuritis, that is to say, by an injury of the nerve substance in the 
erection center in the lumbosacral medulla, or in the corresponding nerve 
centers. [J.] 



Nicolas and Roy. Herpes of the Buttock, Penis, and Scrotum. 
[Lyon Medical, 1919, CXXVIII, April, p. 204.] 

The writers reported to the Medical Society of the Hospitals of Lyons 
or. March 18, 1919, a case of herpes of this rather unusual distribution. 
At the onset there were sharp pains, with temporary dysuria. The erup- 
tion was present on the inner side of the right buttock, and extended to 
the right half of the scrotum and penis, the cutaneous areas affected 
being those of the third and fourth sacral dorsal roots. The eruption 
was confluent over the right half of the penis. No objective sensory 
changes were present. [Leonard J. Kidd.] 



SENSORI-MOTOR NEUROLOGY 351 

Niessl v. Mayendorf, Erwin. Touch-blindness After a Gunshot 
Wound in the Posterior Root. [Ztschr. f. d. ges. Neurol, u. 
Psychiat.. Vol. XXXIX, p. 282.] 

A gunshot wound in the left half of the neck on the posterior horder 
of the sterno-cleido-mastoid muscle at first produced signs of bleeding in 
the spinal cord or of compression due to strained or dislocated vertebrae. 
The permanent symptoms were a very perceptible ataxia of the right hand 
and loss of power to recognize objects which were placed in this hand, 
although the length, form, and temperature could be rightly given (touch- 
blindness). A further symptom was disturbance of recognition of posi- 
tion by the right hand. This astereognosis is to be referred to an injury 
of the posterior root. The case shows that the peripheral agnosia differs 
in no respect from one conditioned cortically, and that agnosia need not 
necessarily be a central associative disturbance from a cortex lesion and 
loss of perceptions, but that deficiencies in the tactile periphery or the 
paths of the same resulting in impairment of the finer sense of place 
localized in the skin are sufficient to interfere with the normal function 
of touch, even though all the other sensory qualities are relatively well 
preserved. It was shown besides that the arrangement of the peripheral 
organs receiving the impressions of sense must have an exact duplication 
in the grouping of the nerve elements of the brain cortex which receives 
the fibers coming from the periphery. The interruption of the posterior 
root in the author's case had prevented the awakening of the touch 
impressions. The touch image, which attains to consciousness in the 
cerebrum, must take its way unchanged through the posterior roots to 
the cortex, and disturbances of the sense of place in the peripheral tactile 
surface is of itself sufficient to destroy tactile recognition. [J.] 

Gottfried, G. Nerve Cell Swellings and Accompanying Phenomena. 
[Ztschr. f. d. ges. Neurol, u. Psychiat., 1919, Vol. LXVI, p. 111.] 

Though the fact that nerves swell is not a new discovery in histology, 
yet the various accompanying phenomena, conditioned by the different 
manner in which the swelling is produced and the different constructions 
of the elements affected, is both new and interesting. Schaeffer described 
two forms of nerve swellings, the endogenous and the exogenous. 
Chromolysis is common to both types, but is manifested differently. In 
the endogenous form the chromolysis begins with a pulverization of the 
peripheral layers, while the perinuclear layers at first remain intact, the 
nucleus retaining its central place; it does not swell and even seems to 
grow smaller. In the exogenous type, on the other hand, the swelling 
and chromolysis begin at the nucleus; the nucleus is displaced and is 
often lodged in the periphery. The following explanation is given for 
the two forms of swelling: Where there is exogenous traumatic swelling 
the irritation due to the lesion attacks one point of the cell, i.e., the orig- 
inal extension of the axon which reached into the inner part ; in endoge- 



352 CURRENT LITERATURE 

nous hereditary disease the nerve cell would be affected from all sides, 
and therefore the peripheral Nissl layers would be first attacked. Experi- 
ence confirms the assertion of Schaeffer concerning the nerve swelling of 
external origin, and Stuurman only has observed peripheral chromolysis 
after eradication of a nerve, namely, in the vagus nucleus. As control of 
Stuurman's observation, Gottfried undertook the resection of the hypo- 
glossus of a guinea pig, but this experiment resulted in a central chro- 
molysis with relative preservation of the peripheral layers, corresponding 
with the facts observed by others. The exogenous traumatic type of 
nerve swelling may arise from causes of various nature, division, eradica- 
tion, hemorrhage, pressure, etc., but in all the resulting forms the author 
found one factor constant — the injury of the neuron as an entity. The 
end results are in proportion to the intensity of the injury, and there may 
be recovery or total destruction of the swollen nerve cell. It must not 
be lost sight of that the characteristics of the exogenous injuries are 
established by experimental proof, but that for the endogenous injuries 
there is as yet nothing more than a theoretical foundation. [J.] 

Sabrazes, J. A Case of Bilateral Meralgia Paraesthetica. [Gaz. 
Hebd. Sci. Med. de Bordeaux, 1919, XL, July 6, p. 152.] 

Meralgia paraesthetica is almost always unilateral, but a case of 
obstinate bilateral meralgia is recorded briefly by Sabrazes. It occurred 
as a sequel of a very difficult labor in a woman whose thighs had been 
kept for a prolonged period in a position of abduction and semi-flexion 
on the pelvis. This posture produced stretching of the cutaneous nerves 
of the femoral region, and so set up the bilateral meralgia paraesthetica. 
[Leonard J. Kidd.] 



Book Reviews 



Brissot, M., et Bourilhet, H. La Demence chez les Epilep- 

tiques. [A. Maloine et Fils, Paris.] 

This is a small volume, very clearly written, from a strictly clin- 
ical view of the mental states observed in epileptics. The authors 
have perhaps wisely refrained from any doctrinal presentation in 
view of the extreme complexity of the problem. 

They have chosen to describe the progressive and incurable deteri- 
oration of intelligence which occurs with certain epileptics after a 
longer or shorter interval of the disease. In some respects regarding 
epilepsy as a syndrome, in others as a disease, they have not always 
clearly distinguished the two aspects, but in general the little volume 
is remarkably clear and succinct on the clinical side. Any deeper 
interpretation of what intelligence really is is not touched upon. 



Zeihen, Th. Axatomie des Cextralxervensystems. Zweite 
Abtheilung. Zweiter Teil. Mikroskopische Axatomie 
des Gehirxs. [Gustav Fischer, Jena. 25 marks.] 

Ziehen's justly prized continuation of the anatomy of the central 
nervous system in Bardleben's monumental contribution to human 
anatomy here occupies itself with the microscopical anatomy of the 
hind brain. 

Here following his method of describing successive series of 
cross sections with very excellent microphotographic reproductions, 
Ziehen follows through the important details of structure of the pons 
region. Interspersed between the serial sections illuminating illus- 
trative schematic sketches are given of the pathways connecting the 
nuclear topographies, and many intricate and complex points in the 
anatomy of this region clearly portrayed. The entire volume of 
approximately 300 pages is taken up with the discussion of the 
pontine structures. 

Detailed consideration of the many problems involved is out of 
the question. Ziehen's extensive knowledge and his clear-cut intel- 
lectual appreciation of the many possible interpretations, his inde- 
fatigable research and broad grasp of all of the available studies, 
makes this section of his anatomy, like that of his preceding volume 
published in 1913, of inestimable value. No similar work of so 
detailed significance and definite authority is available up to the 
present time. No student of the finer anatomy of the brain can 
neglect the rich material here offered. | Jelliffe. | 

[3:3] 



354 BOOK REVIEWS 

Knight, M. M., Peters, Iva. L., and Blanchard, Phyllis. Taboo 
and Genetics. [Moffat, Yard and Company, New York.] 
A work purporting to deal with the biological, sociological and 
psychological foundation of the family is no mean order, if it is to be 
seriously considered and of value to medical readers. This book is 
so considered, and the three authors have each dealt with the material 
in an extremely interesting and profitable manner. Dr. Knight has 
discussed the biological foundations of sex, Dr. Peters has taken up 
the gradual growing up of institutional control or regulation of the 
biological instinctive drive that makes creative evolution possible, 
and Dr. Blanchard has discussed the psychological integrations that 
have arisen — both conscious and unconscious — to make the guidance 
and control more and more adaptive to human permanence and 
individual happiness. 

While we might find fault with a certain fragmentary type of 
exposition, on the whole a most difficult task has been rather 
acceptably accomplished. 

Edinger, Ludwig. Einfuhrung in die Lehre vom Bau und 
den Verrichtungen des Nerven-systems. Ill Auflage von 
Kurt Goldstein v. A. Wallenberg. [F. C. W. Vogel, Leipzig. 
80 marks.] 

Fortunately for neurology, Edinger's death has not prevented a 
new edition of his celebrated Introduction, the last of which appeared 
nearly 10 years ago and was of so much value to a former generation 
of neurological students. Again fortunately the publishers have 
found two collaborators whose competency to re-edit in a sympathetic 
manner this masterpiece of neurology is well recognized. 

Whereas but few real changes have been introduced into this new 
edition, the foundations of Edinger's work have been deepened and 
minor points cleared up, making it, as it has been for so many years, 
one of the most important works of its kind for neurological students. 

Lehmann, Walter. Die Chirurgie der peripheren Nerven- 

VERLETZUNGEN MIT BESONDERER BeRUCKSICHTIGUNG DER KRIEG 

Xervenverletzungen. [Urban & Schwarzenberg, Berlin and 

Vienna.] 

One of the largest chapters of war neurology has been that en- 
compassed by the enormously fruitful observations on the peripheral 
nerves. The author has been in charge of the Gottingen hospital for 
these types of injury and has here given us the results of his neuro- 
logical as well as surgical studies. Space does not permit us to go 
into detail concerning this splendid book. It is extremely well gotten 
up, beautifully printed and richly illustrated in color and line. The 
entire field has been extremely well covered. The literature is 
especially well collected. It supplements in a very complete manner 
the excellent work of Tinel on the same subject. The French 
neurologist has given us a work of paramount value from the clinical 
neurological side. This is an excellent companion volume on the 



ROOK REVIEWS 355 

neurosurgical aspect of the most important subject of practical as 
well as theoretical interest. 

Freud, Sigmund. Sammlung hleinkr Schriftkn Sub Neuro- 
senlbhre. 1893-1906. [Dritte Auflage. Franz Deuticke, 
Leipzig and Vienna.] 

A third edition of the first collection of Freud's opera minora has 
been called for showing the steadily advancing interest taken in these 
shorter articles. They have been reprinted as they originally ap- 
peared and hence are available for those who have not heretofore 
been able to possess them for their own libraries. No added word 
of commendation is needed for this really remarkable series of pene- 
trating psychological contributions. 



Ralph, Joseph. The Psychology of Nervous Ailments. 
[Torquay Publishing Co., England.] 

In slender brocure the author has written a very clear and succinct 
summary of the general Freudian doctrine of psychoanalysis. It is 
a very acceptable short primer of the general fundamentals. 



Baur, E., Fischer, E, Lenz, F. Grundriss der menschlichen 
Erblichkeitslehre und Rassenhygiene. Band I. Mensch- 
liche Erblichkeitslehre. Band II. Menschliche Auslese und 
Rassenhygiene. [J. F. Lehmanns Verlag, Miinchen. $2.60 
bound in one volume.] 

Whether the world catastrophe is going really to teach human 
beings anything or not, one situation is evident. That is the increas- 
ing interest taken in the problems of heredity and in race hygiene, 
evidence of which is contained in these two excellently prepared 
volumes. 

The first contains a most thorough exposition of the recent acquisi- 
tions relative to general problems of human inheritance ; the second a 
penetrating discussion of the fundamentals of race hygiene. 

Interesting as the former series of questions may be. and ably pre- 
sented as they are. the reviewer regretfully feels that little is to be 
gained from them of value to the evolution of human capacity to get 
on with its neighbors. Studies in heredity do not cover sufficiently 
the many important questions of environmental adaptation. They 
unfortunately are too static and pessimistic. They tell us a great 
deal about organ inferiorities but not much how to socially adjust 
to them. They lack the inspiration of effort to ameliorate conditions 
on the l)asis of individual idealism — they provide too ready a hypo- 
critical retreat for the strong to take advantage of the weak, for the 
unscrupulous majority to profit at the expense of the more highly 
advanced ethical minority. They offer too much opportunity to make 
charts, and too little to work with psychological factors that make 
citizens. . .J 



356 BOOK REVIEWS 

Towards meeting this hiatus in concerted effort to improve the 
racial phylum the contributions to Vol. I, however, afford some ele- 
ments of a progressive attitude. As such they are welcome and to be 
encouraged and the book to be carefully studied. 

Vol. II contains a host of extremely valuable suggestions about 
human imperfections and practical issues that come out of them. It 
equally is full of common sense directions whereby these human 
imperfections, arising, it may be, from faulty hereditary factors, may 
be advantageously handled by human made institutions — laws — relief 
societies — insurance — etc., etc. 

Two extremely valuable and helpful volumes for all neuro- 
psychiaters interested in social problems, and particularly for those 
who would gain an inkling of what formulations are being constructed 
by a defeated nation pushed to the extreme to make better adaptations 
to vital problems or go under. 

Acute Epidemic Encephalitis. By the Association for Research in 
Nervous and Mental Diseases. [Paul B. Hoeber, New York.] 

This unique Association which has for its main object the annual 
discussion of one topic of neuropsychiatry interest here presents a 
general abstract of the papers presented at its first annual meeting 
held in New York in 1920. 

Since " lethargic encephalitis " presented an acute, recent and 
definite series of problems this subject was timely chosen. What 
has been learned about the disease is here very acceptably abstracted. 
It is a valuable production and is to be cordially recommended to all 
neuropsychiaters. 

Kronfeld, Arthur. Das Wesen oer psych iatrisch en Erkennt- 

niss. | Beitrage zur allgemeinen Psychiatrie I. Julius Springer. 

Berlin.] 

Kronfeld has written here a big book. Its 500 pages are crowded 
and full of thought only the merest indication of which can be regis- 
tered in this place. 

After a preliminary statement regarding the possibilities of a 
metaphysically free nature investigation, the distinctions between a 
theory of knowledge and a critique of reason and a short outline of 
the Friesian school of philosophy he enters into the chief portions of 
his discussion. 

The present tendencies in German psychiatry and psychology are 
extremely diverse and Kronfeld has given a most able summary of 
them. We recommend this extremely thoughtful and philosophical 
treatise to serious students of German philosophical-psychiatric 
tendencies. It is entitled to a much more extensive and critical 
review. 

Bregman, L. E. Die Schlafstorung und ihre Behandlung. 

[S. Karger, Berlin.] 

In a short, readable monograph the author discusses this very 
important problem in all of its many sided aspects. He treats of it 



BOOK REVIEWS 357 

in a purely clinical manner and reflects the great mass of material 
that has grown up about the subject without any special doctrinal 
attitude. It is a good clinical presentation, not penetrating, but well 
adapted to the general requirements. 

Saleeby, S. W. The Eugenic Prospect. National and Racial. 
[Dodd, Mead & Co., New York.] 

Notwithstanding the well-recognized feuillotonistic tendencies of 
the author, his superficiality, and his egocentric attitudes towards 
many pressing problems, he nevertheless has a knack of getting vital 
issues on to the platform, and of stripping them down to some sort of 
reasonable form for progressive discussion. 

We therefore feel justified in recommending the reading of this 
book by our readers. One does not want to swallow him wholesale, 
but with discrimination digest the definite issues he brings before the 
thinking public. 

Conklin, E. Grant. The Direction of Human Evolution. 
[Chas. Scribner's Sons, New York.] 

This is an extremely readable book, fascinating, well written and 
for the most part to be accepted. The aim of true science as well as 
religion, he tells us, is to know the truth, confident that even unwel- 
come truth is better than cherished error; that the welfare of the 
human race depends upon the extension and diffusion of knowledge 
among men, and that truth alone can make us free. He leaves out 
" wisdom " here, forgetting Wordsworth's famous antithesis between 
" knowledge " and ■ wisdom." For much so-called knowledge is 
after all built on very shifting sands of custom, opportunity, and, 
regretfully must it be said, often wilfully directed propaganda. 

The day has passed, says Conklin, when among thinking, know- 
ing, and wise people, the general conception of evolution in its widest 
sense needs to be argued about. It has become a valued tool of 
progress to aid in solving large problems of social conduct, of govern- 
ment and of religion, and of ethical systems of national and 
international import. 

It is with this large viewpoint that nothing which concerns man 
is foreign to the fundamental principles of life and evolution, that 
the author sees his general problem and moves on to describe it. He 
is not daunted by Chestertonian witticisms, about the death of evolu- 
tion, for never in the history of mankind has there been a more 
tremendous need to gather up what scientific observation has told us 
of the forces operative below conscious levels, and to put ourselves 
in line with these forces and grow upward and onward. 

He has told his story plainly, succinctly, sanely and with good 
perspective. Only one series of factors of paramount importance 
are neglected — so the reviewer senses it. When he tells us there is 
not much capacity for individual evolution ; that in mind and in body 
the peak has been reached ; that only in social or mass evolution are 



358 BOOK REVIEWS 

to be observed the fruitions of man's already achieved powers, we 
raise issue with the methods with which, as a biologist and student of 
evolution, he has girded up his scientific loins and advanced his thesis. 
He is weak on the psychological side of evolution and unappreciative 
of the signs by which advance may be registered and structuralized 
into fundamentals of advance. Apart from this, the general proposi- 
tions laid down, save in minor details, are valid and helpful. We 
recommend this work to our readers, mindful of the general criticism 
that the teachings of neuropsychiatry could have been integrated into 
his argument to its advantage and our profit. 

Bailey, Harriet. Nursing Mental Diseases. [The Macmillan 
Co., New York.] 

For an excellent, systematic, readable account for nurses of mental 
patients this is a thoroughly well done piece of work. It should be 
available to all those doing this branch of service in the community. 

Janet, Pierre. The Major Symptoms of Hysteria. Second 
Edition. [The Macmillan Company, New York.] 

Thirteen years have elapsed since the first edition of this — then 
most masterly review of the hysterical syndrome — was published. 
The author has thought it inadvisable to modify it. He rationalizes 
this conclusion behind the belief that one would confusedly mix the 
ideas of one period with those of another, and in his preface would 
attempt an outline of his own advanced position relative to this group 
of manifestations termed hysteria. 

These advanced positions, however, are but a feeble effort to 
evade the newer points of view relative to our knowledge of the 
conversion mechanisms which permit the so-called hysterical reac- 
tions. Unfortunately Janet has been unable himself to amalgamate 
the new learning with the old, and the result is an attempt to stem 
the tide of psychopathological advance rather than to swing loose into 
its tendencies and recast an old series of formulations, now more or 
less useless to the younger generation. It therefore is to be recom- 
mended as a historical document, recording a certain stage in the 
evolution of the hysteria concept made momentous by the brilliant 
descriptive talent of an adherent of the Charcot school. 

Rivers, W. H. R. Instinct and the Unconscious. A Contri- 
bution to a Biological Theory of the Psychoneuroses. [Univer- 
sity Press, Cambridge, England.] 

Our review of this most masterly work has been too long delayed. 
For it represents, to us at least, one of the real contributions within 
the past five years to the study of the psychoneuroses. 

This is due to the fact that the author has brought a rich anthro- 
pological experience to bear upon the most important of psycho- 
pathological advances of the past generation, namely the Freudian 
contributions. 



BOOK REVIEWS 359 

Inasmuch as Freud has reared his chief structure upon the 
phyletic history of mankind, as stored up in unconscious activities, 
manifesting themselves in a rich variety of symbolic outlets in meta- 
bolic disharmonies and in human conduct, the vision of an observer 
who has devoted a large part of his activities to such phyletic and 
racial components is especially valuable. They bear out the chief 
fundamentals of the Freudian psychology. 

When the massive psychopathological probings of the World War 
were thrust en bloc directly and decisively upon the heretofore com- 
placent medical mind, they necessitated a radical readjustment of the 
old views, and fortunately there were not lacking some who resolutely 
took off their coats to wrestle with the problems. Rivers was one of 
these, in England, who had breadth of vision and sufficient back- 
ground to see the new dawn, and this and other important communi- 
cations have issued as the result. 

Furthermore, he has made a valiant, though less well-grounded 
effort to swing these observations into the general biological field, on 
the basis of physiology. The result is a real advance in outlook and 
a volume which demands attention and is entitled to great praise. 

In only two points does the reviewer feel called upon to say a 
word of disapproval. These center about the use of the word sup- 
pression, and the utilization of the " all or none " principle — a prema- 
ture and questionable generalization of physiology, i.e., using these 
critical words, not as necessarily applicable to the limited physical 
concepts as registered in electrophysiology, but as to their usefulness 
in the more complicated reactions of psychopathology. 

Just why Rivers should reverse the usually accepted meanings of 
suppression and repression in the Freudian psychology is not clear. 
Perhaps it is on the basis of the execrable translation of Freud's 
General Introduction, where the real meaning of these words as 
carefully discussed by Freud is entirely lost sight of, or because of 
an incorrigible tendency of certain personalities to go counter to 
accepted definitions for fear of being considered servile, we cannot 
say. At all events, this introduces confusion and is disadvantageous. 

As for the " all or none " principle, we seriously doubt its value 
in a dynamic psychology where relativity is a ruling principle rather 
than absolutism. 

Apart from these points of discontent with the author's method 
of handling the problems involved, we feel that the volume under 
consideration is one of great value. With increasing experience 
which will come from quiet and intensive study of individual cases — 
and which the work gives some evidence of lack — we feel that the 
author will produce further work of lasting value in psychopathology 
should he continue his researches in this field. 

Edridge-Green, F. W. The Physiology of Vision. With 
special reference to Colour-Blindness. [G. Bell and Sons, Ltd., 
London.] 

When Socrates, that doughty champion of absolutism of old, 
sought to impose his say so upon his Athenian disciples, he encoun- 



360 BOOK REVIEWS 

tered a particularly irritating person called Protagoras, who kept 
continually saying " let us see about the facts." I enjoy your general- 
izations about what ought to be, Mr. Plato — but what is I Interest- 
ingly enough this same Protagoras utilized the facts about 
color-blindness as representative of his general attitude about " truth 
and reality." For in his famous dictum, that he took from his 
master, Heraclitus, that " man was the measure of all things," he 
outlined the pragmatic doctrine that " truth and reality were to each 
man as he saw things." 

This work, the author tells us, has evolved, not on a basis of what 
people have said — and authorities ( ?) often they were — about what 
color-blindness ought to be, but what he actually found it to be. It is 
a result of observations on vision and on color vision which reveal 
new facts apart from any theory and so are applicable for any theory. 

It is refreshing to find an observer cut himself loose from all the 
things that " ought to be " and to record things as " he found them." 
He, even more refreshingly, admits that they are " individual obser- 
vations." Thus he proclaims not wittingly, but unwittingly, that he 
is a true observer. He thus hopes that his book will be one that will 
help students to observe for themselves and not be slaves to what 
others have maintained to be the truth. For truth is always in a 
state of flux, and cannot be rendered static and fixed if evolution of 
conceptions relative to nature's vast accumulation of secrets are to be 
made available for progress. 

He thus would call attention to the many fallacies surrounding 
old methods of testing for color vision and outlines new and better 
methods of vast scientific and economic value. 

Neurologists are interested in color vision. They use methods of 
testing for the determination of brain-tumors and many things, other 
than the needs of locomotive engineers, etc. Hence we feel that this 
most refreshing and salutary work on color vision is available. 

Reik, Dr. Theodor. Probleme der Religionspsychologie, I 
Teil. Das Ritual, flnternationaler Psychoanalytischer Verlag, 
G. M. B. H., Leipzig and Vienna.] 

The far-reaching interest awakened by the studies embodied in 
this book makes one hope that this is only indeed a first part of a 
series of investigations which will follow. The author's own sym- 
pathetic interest has evidently been stirred whether to search into 
some of the broad evidences of folk custom widely distributed among 
primitive peoples or to investigate the deeper significance of special 
phenomena in the religion of a single people. He turns the pene- 
trating light of psychoanalysis down toward the hidden origins and 
into the psychic significance of these phenomena. For his interest is 
a double one: He utilizes psychoanalytic research better to under- 
stand the complex threads of individual problems through the finding 
and following of these in racial or group institutions. He also brings 
psychoanalysis to bear upon the great problems which confront all 
students of race and group belief and practice. The interrelation of 



BOOK REVIEWS 361 

the two fields for psychoanalysis is suggested also by Freud in his 
introduction to the work. 

The subjects treated here are the couvade, a name given to cer- 
tain regulations to be observed by a man toward his wife and child 
at the birth of the latter, and the relation of it to the unconscious fear 
of retribution. The widespread rites pertaining to puberty receive 
penetrating study. Then attention is given in the same manner to 
a curious form of absolution in advance from the guilt of failure to 
fulfill oaths, perform vows and the like, found in the Jewish religion 
under the form of an ancient song, Kolnidre. The remaining study 
is of the place of the ram's horn as a sacred instrument among this 
same religious people. The book combines the sympathetic attitude 
of the cultural student with the clear insight of the profound 
psychologist. 

Abraham, Karl. Klinische Beitrage zur Psychoanalyse aus 
den Jahren 1907-1920. flnternationaler Psychoanalytischer 
Verlag, Leipzig, Vienna, Zurich. 

This collection of papers presents an amount of valuable material 
in a specially available manner. Abraham has collected it from an 
experience of fourteen years which brought him at first in a more 
restricted form into contact with important problems of psychiatry 
and psychotherapy and then through his private practice into the 
more extensive use of the principles of psychoanalysis. The papers 
are presented in such brief form, the discussions with their illustra- 
tions from individual case histories are so clear and straight to the 
point that they may be easily consulted for a moment's helpful read- 
ing in the problems that confront the practical psychoanalyst or for 
a more prolonged study. In either case the reader looks through the 
eyes of a keen and sympathetic worker in the field. His work has 
enriched his understanding of the problems involved throughout the 
years in which these papers have been collected, but has not altered 
fundamentally his original appreciative point of view. An English 
edition of this collection will be available in time for his readers. 

Danmar, William. Modern Nirvanaism. [Jamaica, New York.] 

Inasmuch as a constructive psychiatry is interested in all forms of 
symbolic formulations as attempts at functional discharge of the 
libido and ego urges, this small volume, belonging in the general 
group of mystic or spiritualistic categories, will be of interest as 
illustrative at the same time, an individualistic craving satisfaction, 
and a group type of symbolic activities functioning to keep man's 
reason within the broad road of social adaptation. 

Watkin, Edward Ingram. The Philosophy of Mysticism. 
[Harcourt, Brace and Howe, New York.] 

It is not many years ago since the general type of mind expression 
which this work gives in masterly review was in a sense universal. 



362 BOOK REVIEWS 

Men like Galileo were of a type who were stoned by the reigning 
majorities that upheld the mystic traditions. 

Today the pendulum has swung too far the other way, and we 
find as bigoted and stupid attempts to stone those who would fain 
use the mystic form for expression, as were the efforts made in the 
Middle Ages to clip the wings of the scientific type of adaptation to 
nature's forces. 

Fortunately these stupid bigots — and some are found in our 
universities — cannot prevent the wider and more intelligent scientific 
attitude that counsels one to study phenomena and find out why they 
exist instead of shortsightedly and impatiently trying to crush them 
by silly, noisy denunciation. 

It is from this wider viewpoint that real scientific curiosity would 
approach the investigation of phenomena coeval with the birth of 
mankind and steadily progressing as a part of his adaptation to 
social forces. Never, within recent years, at least, has there been 
so much interest in the general subject of mysticism, and at the same 
time so many publications issued from all quarters of the world of 
letters and books. 

Of the many works which mark this period of increasing interest 
this one under consideration is of great excellence, not only by its 
stamp of learning but by reason of its breadth of sympathetic feeling. 
The author attempts a metaphysic which is implicit in mystical experi- 
ence, a philosophy of mysticism. This Watkins defines as a philoso- 
phy which is a body of truth about the nature of ultimate reality 
and of our relationship to it to be derived from the content of 
mystical experience. This metaphysic he would erect upon a doctrine 
of ultimate reality, of God, as the unlimited, and of the consequent 
relationship between man's limited soul and the unlimited. Thus the 
author would attempt a philosophy of the unlimited. 

St. John of the Cross is taken as a general prototype as one of the 
greatest of all mystics of actual attainment, and as one who, in 
contrast with most mystics who have described their experience in 
confused and disordered form, has been unrivalled in his capacity 
for penetration, clarity and harmony. The Spanish School is taken 
as the clearest exponent of coherent and methodical exposition. 

It would take us too far afield to attempt a critical resume of this 
really absorbing work if one can by a twist of the usual medical mind 
throw oneself into sympathetic understanding of what is being 
attempted. Whether it makes the matter any clearer or not by say- 
ing, in such medical terms, that one is trying to get into intuitive or 
instinctive relation to the unconscious, usually the collective uncon- 
scious, of Jung, is a matter of real insignificance — the point is this is 
the way many people express their experience, and as such is entitled 
to careful consideration. One does not explain nor understand 
phenomena by calling them by opprobious terms — a fashion too long 
reigning in so-called orthodox science. 



BOOK REVIEWS 363 

Thomson, J. Arthur. The System of Animate Nature. In 
Two Volumes. [Henry Holt & Co., New York.] 
The Gifford Lectureship in the Scottish Universities is among 
those institutions which English social custom has founded and 
endowed as one of the hoped for instruments of advancing human 
welfare. The present volumes contain one of these series of endeav- 
ors which, printed in black and white, offers evidence of this hope 
and inspiration. 

Many illustrious predecessors have done their bit — to what 
eventual ends only an omniscient intelligence can interpret. The 
desire of the founders was that each lecturer should, from his own 
special studies and in his own way, endeavor to make such contribu- 
tions that would help others in considering the highest questions that 
man can ask. What kind of a world is this in which we live — a 
universe or a multiverse ? How has it come to be as it is ? Does it 
give any hint of a purpose? What is man's place in Nature? To 
what extent does our knowledge of Nature conform with our 
conception of God? 

The one conception of the founder of these lectures was that it 
should be approached in a reverent, i.e., a serious, manner. A bio- 
logical approach has seemed to the author to fall within this concep- 
tion. Nature as a temptress no longer holds sway. This is a purely 
theological conception. Nature as an orderly arrangement — a system 
of principles to be understood and to be followed, improved upon if 
possible — in the light of past efforts — this is a practical pragmatic 
conception. Thus the author has thought to array our body of 
biological conceptions as an aid to show what God may be — to carry 
on the thought of the founder of these lectures : The organism as a 
mechanism; the determinism of heredity; the struggle for existence. 
Is life a dismal cockpit after all and is mind a purely negligible quan- 
tity? — these among other things the work here discussed is projected 
to answer. Is evolution a chapter of accidents — is fate after all 
insurmountable? Such views, the author would show, while they 
tend to engender a natural irreligion, are scientifically untenable. 
Thus he sets himself the laudable task to combat a pessimistic 
philosophy and to construct an optimistic platform. 

The wish as father to the thought leads him to reconcile these 
conflicting tendencies and in a most charming and well-grounded 
series of reflections leads him to the conclusion that law and order 
are of nature's building, and that Nature and Religion are not so far 
apart as a too narrow view of biological principles might assume. 

In these two volumes Thomson has developed in a most fascinat- 
ing and entertaining manner the general conclusion that, notwith- 
standing the general assumption that Animate Nature lias led to a 
disappointing balancing of alternative propositions, a more wide-eyed 
vision of the biological and psychobiological concepts of organism, 
behavior, development, heredity, involution, and so on, which must 
be viewed in a philosophical view of Nature, lead to a definitely pro- 
gressive attitude that the ways of God — which from a theological 



364 BOOK REVIEWS 

attitude must be left to those conversant with theology — are the ways 
of Nature, and are interpretable by science. 

Schultz, I. H. Die seelische Krankenbehandlung. Psycho- 
therapie. Zweite, verbesserte Auflage. [Gustav Fischer, Jena. 
'48 marks.] 

The first edition of this work appeared in 1918, and by reason of 
international politics could not be brought to our readers' attention. 
As it is a somewhat pretentious work, aiming at a large resume of 
leading thoughts in psychotherapy, it is entitled to serious 
consideration. 

At the outset it may be said we know of no work with as broad 
a platform in any language. Janet's recent three volume work might 
compare with it were it not such a hodgepodge of old and new 
material, illy organized and poorly synthesized. Walsh's large book 
in English might be set up in comparison, but it too shows such 
temperamental biases as to put it in the class of special pleading, 
very wordy and very interesting, but hardly passing as a logical 
argument based on actual experience. It lacks insight of the actual 
problems of psychiatry. Schultz's book, however, gets down to 
brass tacks, and is a logical and scholarly discussion of psychothera- 
peutic needs. 

Psychotherapy is the most intricate and involved of all types of 
therapy. A real master must have a grasp of scientific data vouch- 
safed to but few of those who practice it. It is not the superficial 
appeal to emotional forces so prevalent in its practitioners, who work 
more havoc with human destinies than they can possibly conceive of. 
Thanks to intuitive forces they are not capable of accomplishing 
the bad results their shifty character might produce. Even the sick 
psyche knows the fakir and the charlatan, and only momentarily 
sinks to the level of the Atlantic City boardwalk homosexual pervert 
or the Hindoo pederast, disguised though often in great dilutions 
behind the high enema protagonists. From all such, even the most 
ultra scientific intestinal toxemia quack, a healthy residuum delivers 
them. With all these phases of human weakness psychotherapy must 
reckon. 

The present volume comes as near to an appraisal of the various 
problems as we could expect, even though at times the author slurs 
over most fundamental situations, and unduly idealizes human capaci- 
ties for perverse gratifications. This is the chief fault of the work 
under discussion. The author seems afraid to come to grips with 
certain actual situations. Love, hate, and anger, money, envy, and 
greed, he does not wish to see. He seems to desire to cover them 
in a cottonbatting of Latin and Greek terminologies and handle them 
with tongs and forceps, from afar. The modern cry of getting 
down to essentials — he would seek to evade and cover up behind a 
terminological verbiage of diplomacy. 

Notwithstanding this scientific prudery we heartily recommend 
this very intellectualistic product. 



HOOK REVIEWS 365 

Galloway, Thomas W. The Sex Factor in Human Life. 

[The American Social Hygiene Association, New York.] 

Written as this volume is expressly and primarily for groups of 
college men joined together for voluntary discussion of those points 
at which sex hears most directly upon the happiness and sanity of 
every life, the chief if not the only problem of the reviewer is to 
>tate wherein and how well it furthers these goals. 

In general our reaction is one very favorable to the work, both 
as to its manner and its material. 

He starts with statements of human appetites as biological hered- 
itary patterns of value and of importance. The sex instinct is then 
taken up specifically. Then right and wrong uses of appetite are 
discussed, and then chapters on related subjects follow, all brought 
together in question and answer form. This form has its advan- 
tages and disadvantages. The author has woven a very useful 
fabric — a little too elementary, we believe, for college students, for 
they should be able to go further into the problems of rationalization 
and of repression and the various camouflages that reveal more than 
they conceal — to the inquiring student— of the faulty uses of the sex 
apj>etite hiding behind disguises which are seldom penetrated, or 
revealed after serious disaster has resulted. 

Kyrle, J. Syphilis. Zweite Auflage. | Franz Deuticke, Leipzig 
v. Wien, 1922. Mk. 17.] 

As an assistent in Finger's clinic in Vienna, one of the most 
widely recognized sources for advanced methods of treating this 
disease, Kyrle outlines the present day developments for the mastery 
of this most dreaded factor of neuropsychiatric disorder. It is a 
clear cut, concise and able summary of the general therapeutic 
resources. 

Cestan et Verger. Precis de Pathologie Interne. Vol. IV. 
System f. Xerveix. Troisieme Edition. [Masson et Cie, Paris. 

Fr. 2S. ] 

This compact volume contains one of the most complete and 
practical summaries of the pathological anatomy of diseases of the 
nervous system with which the reviewer is acquainted. It is to be 
regretted that almost no work of its kind has appeared in English 
for a number of years. While not as exhaustive as recent similar 
works in Italian. German, and other European tongues, it is one that 
can l>e beard Iv commended. 



Czerny, Ad. Der Arzt als Erzieher des Kindes. Sechste 
Auflage. [Franz Deuticke, Leipzig v. Wien. Mk. 13.] 
In these very readable short lectures Czerny outlines the oppor- 
tunities that exist for the physician to be an educator of youth. He 
has handled the matter most sympathetically and genially and shown 
most convincingly that such an important role should not l>e neglected 



366 BOOK REVIEWS 

by the medical profession if they would most truly conserve the 
health of the oncoming generations. 

Freud, Sigmund. Sammlung kleiner Schrikten zur Neuro- 
sexlehre. Zweite Folge. Dritte Auflage. [Franz Deuticke, 
Leigzig v. Wien.] 

Occasion has been taken of calling attention to a new edition of 
the first series of collected papers of Freud's on the neuroses. Here 
is a third edition of his second series of similar papers. The chief 
papers here are his Fragment of a Hysteria Analysis; Testimony 
and Psychoanalysis ; Compulsions and Religious Rituals ; Character 
and the Anal Erotic — of particular value to the self-constituted 
prophets who have predicted for the past fifteen years that Freud's 
teachings were a dead issue ; Hysterical Phantasies and Bisexuality ; 
The Hysterical Attack ; Sexual Explanations to Children ; Infantile 
Sexual Theories; Cultural Sexual Morality and Modern Nervous- 
ness; The Poet and Phantasy. This third edition will make avail- 
able to the present day increasingly greater number of serious students 
these fundamental newer visions of the problems connected with the 
psyche. 

Harvey, E. Newton. The Nature of Animal Light. [J. B. 

Lippincott Company, Philadelphia and London.] 

Another very satisfactory and readable monograph as the fourth 
in the series on Experimental Biology, edited by Loeb, Morgan and 
Osterhout. 

The general problem of bioluminescence, while of interest in more 
restricted fields, nevertheless is of some applicability in neuropsy- 
chiatry disciplines. 

Here are special cases of photochemical reactions, which in the 
highly synthesized human machine are most prominently met with 
in the human eye and in the pigment of the human skin. With the 
former medical science has some trifling acquaintance; with the 
latter it is in abject ignorance, save for a few suggestions here and 
there, chiefly from dermatologists. 

For the student of neurology who is interested in its activities 
from a broad dynamic viewpoint, rather than from a study of its 
problems at narrower economic levels, this work will prove suggestive 
and valuable. 

Burr, C. B. Practical Psychology and Psychiatry. Fifth 
Edition. [F. A. Davis Company, Philadelphia.] 

While originally this work was intended for training schools for 
attendants in mental hospitals, its value has extended its use to a much 
wider reading public. We have heretofore stated our belief it is 
one of the best of its kind. The new addition has improved it and 
made it even more valuable for lay readers as well as for medical 
men, and even specialists. 



BOOK REVIEWS 367 

Hellpach, Willy. Die Geopsychische Erscheinungen. Zweite 

Auflage. [Wilhelm Engelmann, Leipzig.] 

This is one of the books held up by post difficulties. The first 
edition was already in press when the war broke out. It was held 
up and in 1917 appeared completely here as a second edition. The 
influence of climate, of climatic resorts, of geological, geographical 
and other similar factors, is considered in its relation to the mental 
life — its diseases and its possibilities for restoration and health. 

No similar systematic work of the kind is known to us; there are 
large works on climatology, to be sure, but none that deal with these 
specific applications in a really psychological manner. Weather — 
sunlight, cloud and rain, the temperature, its modifications, the atmos- 
pheric pressure, the moisture of the air, the temperature of the earth — 
these singly and these combined, in their bearing upon the personality 
of the individual, are all most interestingly discussed. 

One of the most interesting series of pages considers periodic 
factors, day and night, spring, summer, autumn and winter, where 
are brought together many interesting data relative to bodily reactions 
and conduct modifications. The ideas that people have of the moon, 
the stars, the sun. etc.. and their interrelated workings upon the 
psyche, these too are exhaustively discussed. Landscape features, 
colors, forms, mountains, lakes, etc., these also are included. 

Altogether a most interesting book, filled with a wealth of material 
of absorbing interest. 

Hall, G. Stanley. Morale. The Supreme Standard of Life 
and Conduct. [D. Appleton and Company, New York.] 
Standards of conduct have been the ultimate search of all philoso- 
phies. Plato attempted in his intellectualistic manner to outline what 
was good and beautiful and the whole effort of most religions has 
been directed to showing the way to get prizes for long life, happiness 
and even everlasting bliss. 

Prof. Hall has here given us, not so ambitious a series of stand- 
ards, but in a simple, practical manner has written a work of great 
value. It attempts to show how the great international regression 
has in its titanic writhings attempted a synthesis of newer principles 
by which healing of the world's woes may ultimately be furthered. 
This he has generalized under the title of " Morale " — those standards 
by which all human institutions and human conduct may be measured. 
This is a super-hygienic philosophy and we can most heartily com- 
mend it to all neuropsychiaters. since it is upon the functioning of the 
nervous system that such a synthesis is founded and made possible. 

Biihler, Karl. Die geistige Entwicklung des Kindes. Zweite 
Auflage. [Gustav Fischer, Jena.] 

The older generation of psychiaters, pedagogs and interested 
fathers and mothers were acquainted with and greatly influenced by 
the work of Preyer on the development of the child. This was 



368 BOOK REVIEWS 

almost the first careful series of observations on infant behavior by 
modern psychological methods. It gave rise to an avalanche of 
similar works until now the whole problem of child psychology has 
an enormous literature. Some of us can recall the early pessimistic 
notes of those who deplored this movement and recall the ironic lines 
about " those who would peep and botanize upon his mother's grave." 
Such has always been and will be the protest of intrenched interests 
and opinions about all efforts at getting at the whys of things. 
Luckily the movement has gone forward and the present volume 
presents an extremely able summary of the studies connected with 
the development of the mind in infancy. While it has for the 
reviewer too close an adherence to older intellectual schemes, based in 
part on the faculty psychology of an over-pedagogic age, nevertheless 
it can be most cordially recommended. 



I 



rt 



VOL. 55. MAY. 1922. No. 5. 

The Journal 

OF 

Nervous and Mental Disease 

An American Journal of Neurology and Psychiatry, Founded in 1874 



Original Articles 



THE TREATMENT OF GENERAL PARESIS BY 
INOCULATION OF MALARIA 

By Professor Dr. Wagner-Jauregg 

CHIEF OF THE PSYCHIATRIC CLINIC IX VIENNA 

We could scarcely speak of a treatment of general paresis and 
tabes which had recovery in view before the knowledge of the 
syphilitic etiology of these diseases had been established. 

There has always been a statistical literature of cases reporting 
the cure of general paresis the beginnings of which reach back for a 
hundred years. 1 Among these cases is a not insignificant number in 
which the cure came after a protracted suppuration or after a febrile 
illness. 2 Among these are some also in which this suppuration was 
produced with conscious intention. 3 E. Meyer 4 has systematically 
made such attempts by rubbing Autenrieth's ointment into the scalp 
of paretics, producing thereby deep suppurations. 

Furthermore, remissions were often observed in the course of 
general paresis as is well known. These sometimes went so far that 
patients for a shorter or longer time were completely able to take up 
their work again and gave the impression of complete mental health. 
It is true that often after the course of weeks or months a regression 
appeared again and the further course was then as a rule a progressive 
one which could not be checked. 

1 Dubuisson. Traite de vesanie, 1816; Bouilland, De l'encephalite, 1820. 

2 A collection of these may be found in Doutrebente, Ann., med. psvch 
T. XIX, 1878. 

3 A case cited by Dubuisson ; further, Trelat, Ann. med. psych., 1895 ; 
Mabille. Ann. med. psych., 1882; Arndt, Deutsche med. Wochenschr., 1872. 

* Berl. klin. Wochenschr., 1877. 

[369] 



370 W A GNER-JA UREGG 

The rare cases of cure as well as the frequent even if temporary 
remissions show that the disease process of general paresis must be 
one capable of remission. 

We began to treat this disease antisyphilitically after the luetic 
nature of general paresis became known, first with the old means, 
mercury and iodides, later with salvarsan. Neither the old nor the 
new treatment of syphilis could boast of special results in regard to 
general paresis. Not that temporary improvement was not to be 
reached in that way in individual cases. The advance of the disease 
could be checked for a longer period especially through salvarsan. 
But the remissions were rarely complete and never lasting. The 
moment came finally, whether earlier or later, in which the fatal 
tragedy could no longer be warded off from the patient. 

The discovery that not rarely psychoses were healed through 
intercurrent infectious diseases instigated me already in 1887 to the 
proposal that one should intentionally imita